Medical Intake Concern Chart

Chief Complaint Complete medical history Child complains of pain to arm due to fall. Medical History is unavailable. Child being cared for while mother is in early labor. Caregiver states child is special needs. Self-hitting observed. Unwilling to keep bandage on. Duration of complaint and progression Family history General Appearance Signs and symptoms Sitting/Moving habits Aggravating factors Child was hurt today while playing outdoors. The child complains of pain during movement but uses left arm and right arm subsequently is aggravated. Unavailable. Caregiver is unable to recall usual doctor Idon receives treatment at. Mild Injury from the incident. Child able to recall the fall. Child has multiple mild abrasions. Child complains about arm when moved. Child is favoring the arms Child has full use of left arm and is removing the splint from right arm and further irritating the sprain. y y y y y y

Education attached and given. Follow-up appt. Prescriptions attached Diagnosis and Treatment Plan
Information from references 1 and 2 provided. Referral to Orthopedic Pediatrics in 14 days.

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Rehabilitation

It may take from several weeks to several months for the injured arm to heal completely. Rehabilitation involves gradually increasing activities to restore muscle strength, joint motion and flexibility.

The patient's cooperation is essential to the rehabilitation process. The patient must complete range of motion, strengthening and other exercises prescribed by the doctor. Rehabilitation continues until the muscles, ligaments, and other soft tissues perform their functions normally. Once rehabilitation is completed, the doctor may want to examine the arm and its function to make sure healing is complete. One common cause of arm pain that affects the upper arm directly, however, is bicipital tendinitis, in which a tendon near the shoulder is frayed or torn, triggering a flare-up of pain in the biceps of the upper arm. If pain sneaks up gradually and hangs on like an annoying relative, there may be a broken bone in the forearm or upper arm. You might think that broken bones are always obvious, but it is possible to experience a fracture without realizing it. You might hit your arm or fall, for example, and not feel the pain until you increase your level of activity or put stress on the broken area.

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Nursemaid's elbow is a partial dislocation of the elbow, which occurs when the lower part of the arm (forearm) slips out of its normal position at the elbow joint. The injury is also called radial head dislocation.

Nursemaid's elbow is a common condition in young children and generally affects children under age 5. The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm up. (For example, when trying to lift the child over a curb or high step.) Swinging a young child from the arms while playing can also cause this injury. When the injury occurs, the child usually begins crying immediately and refuses to use the arm. The child may hold the arm so that is slightly bent (flexed) at the elbow and pressed up against the belly (abdominal) area. The child will move the shoulder, but not the elbow. Some children stop crying as the immediate pain goes away, but continue to refuse to move the elbow. Once the elbow dislocates, it is likely to do so again, especially in the 3 or 4 weeks following the injury. Nursemaid's elbow does not usually occur after age 5. By this time, a child's joints and surround structures are stronger, and the child is less likely to be in a situation where this injury might occur. However, in some cases, the injury can occur in older children or adults, usually from a fracture of the forearm.

Symptoms
y y y y y y y y y

Immediate crying Complaints of elbow pain efusing to use the arm that is injured Holding elbow slightly bent at the elbow Holding the lower part of the arm against the belly area (abdomen) Moving arm at shoulder but not elbow If you think your child has nursemaid's elbow again: DO NOT move the child without first splinting the arm. DO NOT try to straighten the arm or change its position.Apply an ice pack to the elbow. Splint the injured arm in the position in which you found it. Keep the area both above and below the injured elbow from moving, including the shoulder and the wrist, if possible.If the injury is not improving after 3-5 days please return immediately.

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Valley Medical Urgent Care Accident / Injury Report Form

Name: ______Idon Hilton____D.O.B____/___/____/___ Sex: _x__Male ___ FemaleAge:_3yrs___Ht___ Wt___28.2 Address: _______________________________________________________________________________ Street City State Zip Code Telephone: ___(805)210-2338______________ E-Mail: _______________ Social Security #__________________ Parent/Guardian _____Sara Hilton___________________ Other: (specify ) Linda Brown _________________ Date of This Report: ________9/16/2010__________________ Date of Accident: ___________9/16/2010_________________ Time of Accident: ________2-3 p.m. Place of Accident: _caregiver residence/ outdoors

NATURE OF INJURY
Abrasion _x____ Fracture _____ Aspxiation _____ Laceration __x___ Bite _____ Poisoning _____ Bruise _____ Puncture _____ Burn _____ Scalds _____ Concussion _____ Scratches _x____ Cut _____ Shock (el.) _____ Dislocation __x___ Sprain _x____

Other (specify) __Nursemaid Elbow/ Radial Head Dislocation/Subluxation_________________ DESCRIPTION OF ACCIDENT PART OF BODY INJURED
Abdomen _____ Ankle ( ____R / ____L ) Back _____ Arm ( _x___R / ____L ) Chest _____ Ear ( ____R / ____L ) Face ______ Elbow ( ____R / ____L ) Finger ______ Eye ( ____R / ____L ) Head ______ Foot ( ____R / ____L ) Mouth ______ Hand ( ____R / ____L ) Nose ___x___ Knee ( ____R / ____L ) Scalp ______ Leg ( ____R / ____L ) Tooth ______ Wrist ( ____R / __x__L ) Other ( specify ) ___Mild abrasions and lacerations from accident. Primary concern is the radial head subluxation of the arm and complaint of pain in the left wrist. Goggles had pressed into sides of childs nose small abrasion. How did accident happen? What was the child doing? Where was the child? List any specifically unsafe acts and unsafe conditions existing? Specify any objects involved? Additional space available on back. , Child was riding on motor scooter on the back of older children and they had fallen. Child was not wearing shoes possibly only swim trunks or diaper.Unknown if helmet was on, goggles were being worn and had dug into childs nose.

Was First Aid Treatment Given: _x_ YES __ NO By Name: Linda ___ Phone #: (805)210-2338 Email: List First Aid Rendered: arms were wrapped to prevent movement and further injury. Topical Ointment rendered.___________________________________________________________________ Called Parent/Guardian__YES _x_ NO By Name: ____________________ Phone #:__________ Email: ___ Referred to Rehabilitation Services? ___YES ___NO Sent to Hospital? ___YES _x__ NO

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Transported to hospital for further examination/treatment ? ___YES _x__ NO ____Ambulance _____ Parent/Guardian Vehicle ____________________________________ 9/16/2010 16:57

Notes: Child is under the care of caregiver. The parent is not caring for the child due to pre-term labor . Caregiver provided a release from parent for consent to medical treatment. Caregiver administered wrap to child for first aid. Counsel was given as to proper care for injury. Child has special needs which may require splinting to prevent the child from re-injury. Caution to not remove the wrap for next 3-5 days. Ibuprofen given. Continue as needed. Caregiver reports minor cold symptoms being treated with Motrin. Alternate Tylenol and Motrin as needed.

Wei-Chi HuangNP 9/16/2010 16:10

TREATMENT GIVEN Your child required reduction for radial head dislocation. Please follow instructions and return in 3-5 days for follow-up.
Additional Documents on Procedure and Follow-up Instructions Given.

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Accident Prevention Education was provided to care-giver regarding the need to adequately supervise child and provide protective gear and proper garments while outdoors. Caregiver was advised against leaving the child in the care of an untrained individual or unattended/improperly supervised.

FOLLOWUP
Return child in one week to review the progress of the injuries. If the child complains of pain or there is worsening of the condition please return immediately.

HOME CARE INSTRUCTIONS

Your child had reduction. Please fill all prescribed medications and dispense as directed. You may also alternate Tylenol/Motrin for pain. Keep the child still so the injuries can heal and limit recurrence or further injury. Do not allow the child to play outdoors or submerge in bathtub. Do not allow child to remove the bandages. The splint must remain intact. Apply the topical cream as directed 3 times daily on the abrasions. Keep the wounds clean and dry.

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- Patient Presentation: - child presents w/ injured elbow pronated, partially flexed and held by side; - forearm is pronated and the elbow is partially flexed; - there is anterolateral tenderness over the radial head; - this child may not cooperate with keeping the arm immobile; additional support may be necessitated. - the child presents with a flexed and pronated forearm supported closely to the trunk of the body; - the patient complains of pain around the radial head;

- Reduction of nurse maid elbow: - interposed annular ligament was repositioned in its normal site by simple supination of forearrm w/ the elbow in slight flexion; - elbow is gently flexed to 90 degrees by gripping childs forearm above wrist w/ one hand while, w/ other hand, lower end of humerus and elbow are held to prevent rotation at shoulder; - thumb was placed in region of of the radial head for palpation & application of posteriorly directed pressure on the head of the radius, while firmly, supinating and extending the forearm; - childs forearm is firmly rotated into full supination; - immediately following reduction, a click heard and child appeared to have immediate pain relief. -

- Post Reduction Treatment: - immobilization may be necessary for this episode of subluxation. - Following reduction, upper limb is immobilized for 10 days in long arm posterior splint w/ elbow in 90 deg of flexion & forearm in full supination; - if pt has 3 recurrent episodes of subluxation, then apply cast for 3 weeks;

-Pain Relief Instructions - Tylenol and Motrin alternating as necessary.

-Encounter Signoff - Encounter reviewed and signed off by W.K Shimabukuro,N.P Valley Urgent Care

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