Q: Write a full medical record of the patient nguyễn đức long . . I have uploaded a pdf doc which is the patient case record. Now I want to write the case record in the format that I typed below :ORTHOPAEDIC CASE RECORD TEMPLATE I.ADMINISTRATIVE INFORMATION 0.25 pts II. CLINICAL CONTENT: 1. Reason for admission 0.25 pts: The primary reason for the patient's admission 2. History of present illness 0.5 pts: Present all three key elements: mechanism of injury; symptoms following the injury; and first aid/initial management before hospital admission. 3. Past medical history 0.25 pts - Comorbidities - Habits/risk factors related to the primary condition or to the patient's treatment course - Residual impairments of the musculoskeletal system 4. Condition on admission 0.25 pts - Level of consciousness - Vital signs - Key physical findings documented on admission DEPENDING ON WHETHER THE PATIENT HAS ALREADY RECEIVED DEFINITIVE TREATMENT, THE STUDENT SHOULD SELECT THE APPROPRIATE CASE-RECORD FORMAT PREOPERATIVE 5. Ward course 0.25 pts: Summarize changes in symptoms and the management provided 6. Current condition 0.25 pts: Current symptoms 7. Clinical examination 2 pts a. General examination b. Systemic examination 8. Case summary 1 pt: Summarize physical findings and symptoms into symptom/sign groups or clinical syndromes Examples: - Definite signs of fracture: - Signs of compartment syndrome: - Radial nerve palsy syndrome:... 9. Diagnosis 0.5 pts: State the primary injury, associated complications if any injuries, and/or 10. Diagnostic reasoning 1 pt: Explain the basis for the diagnoses listed above 11. Recommended investigations 0.5 pts: Select appropriate investigations according to the site of injury Examples: AP pelvic X-ray: AP and lateral femur X-rays; three-view calcaneal X-rays: etc. Interpret the results of all available investigations. 12. Definitive diagnosis 1 pt: State the primary injury and classification, together with associated injuries and/or complications if any 13. Treatment: a. Treatment plan 0.25 pts: Propose an overall treatment plan. Examples: analgesia, antibiotics, surgery, etc. Note: For the Basic Surgery course, the assessment may end here. Points assigned to the sections below will instead be redistributed to clinical examination +1 pt, diagnosis +0.5 pts, and treatment plan +0.25 pts. b. Specific treatment 0.5 pts: Based on the treatment plan, provide the specific treatment regimen. Example: - Paracetamol 0.5 g, 1 tablet orally three times daily every 8 hours. Open reduction and internal fixation with a locking plate and screws. Explain the rationale for selecting the above treatment method 0.25 pts 14. Prognosis 0.5 pts Short-term: Based on the patient's clinical findings and investigations, predict potential problems during hospitalization,preoperative, intraoperative, and postoperative. Example: The patient has diabetes mellitus and therefore has a higher risk of postoperative infection. A complex fracture may prolong surgery, increase blood loss, and raise the risk of infection. Long-term: Functional recovery and potential late complications or sequelae related to the injury. Example: Early knee osteoarthritis may develop because a complex articular injury is difficult to reduce anatomically. 15. Preventive measures 0.5 pts: Propose measures based on the prognosis to prevent complications. Example: Optimize glycemic control to reduce the risk of surgical-site infection. Plan the operation, prepare all required instruments, select an experienced surgeon, and arrange blood products in advance to mitigate prolonged operative time and blood loss in complex fractures. POSTOPERATIVE 5. Clinical diagnosis 0.25 pts 6. Investigations and results 0.25 pts: Interpret the X-ray findings; describe the fracture location and pattern and any displacement; then provide a conclusion, including fracture classification. 7. Definitive diagnosis 0.25 pts: State the primary injury, associated injuries, and/or complications if any Surgery was indicated for the patient: 8. Operative report if surgery was performed 0.25 pts: Preoperative and postoperative diagnoses Operative duration Estimated blood loss if anyrecord or by asking the surgeon Operative procedure from the medical Other intraoperative events blood transfusion, adverse events/complications, etc. 9.Postoperative/post-cast course 0.25 pts: Describe symptoms only. 10. Clinical examination 1.5 pts: a. General examination b. Systemic examination Postoperative/post-cast follow-up X-rays 11. Case summary 1 pt: 12. Conclusion 0.5 pts: Provide a complete statement of the diagnosis, treatment method, and current outcome Example: Postoperative day 3 after locked intramedullary nailing for a closed fracture of the middle third of the right femoral shaft; clinical course is stable. 13. Further treatment a. Treatment plan 0.25 pts: Propose the ongoing treatment plan Examples: analgesia, antibiotics, surgery, etc. Note: For the Basic Surgery course, the sections below may be omitted except for Comments. Points assigned to the omitted sections will instead be redistributed to clinical examination +1 pt, diagnosis +0.5 pts, and treatment plan +0.25 pts. b. Specific treatment 0.5 pts: Based on the treatment plan, provide the specific treatment regimen. 14. Prognosis 0.5 pts Short-term: Potential problems during hospitalization and the patient's expected ability to perform daily activities and ambulate. Long-term: Bone healing, rehabilitation, and potential late complications or sequclac. 15. Preventive measures 0.5 pts: Propose measures based on the prognosis to prevent complications 16. Comments 0.5 pts: Assess whether theoretical knowledge is consistent with the patient's actual course, from the time of injury to the time of examination.Example: The mechanism of injury is consistent with the fracture pattern. Initial management was inappropriate because the injured limb should have been immobilized at the scene. Surgical management may not have been indicated; for simple, nondisplaced fracture, conservative treatment would theoretically provide greater benefit.
