Distal Radius Fracture Consultation Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Distal radius fracture.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male status post fall straight forward onto right outstretched hand, who presents with complaints of pain and deformity about the right wrist.
PAST MEDICAL HISTORY: Significant for migraines.
PAST SURGICAL HISTORY: Significant for undescended testicle repair.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home with his grandparents. He is in the (XX)th grade. He denies any tobacco, alcohol or IV drug use.
PHYSICAL EXAMINATION: The patient is afebrile with stable vital signs. He is alert and oriented x3. He is not in any apparent distress. Physical examination of the right upper extremity shows deformity and swelling about the right wrist. There are superficial dorsal abrasions over the wrist with no open wounds or lacerations present. The patient is neurovascularly intact. Motor is intact. Positive FDS, FDP, EDC, IO and FPL. Sensation is intact to light touch in the median, radial, and ulnar distributions, and he has 2+ palpable radial pulse.
IMAGING: Imaging of the right wrist shows a distal radius fracture, which is displaced and volarly angulated. There is also a buckle fracture of the distal ulnar metaphysis.
PROCEDURE: With the patient under conscious sedation, it was closed, reduced, and placed in a cast. Fluoroscopy was used during the closed reduction. Post-reduction films showed improved alignment, but there is still slight volar angulation.
ASSESSMENT: The patient is a (XX)-year-old right-hand dominant male with right distal radius fracture. Now, status post closed reduction, in a cast.
RECOMMENDATIONS: At this time include the following:
1. The patient should elevate his right upper extremity for the next 48 hours.
2. He should be discharged home with proper analgesics per the emergency medicine team.
3. He should keep his cast clean, dry, and intact until followup.
4. He should follow up in clinic this week with Dr. John Doe for future planning. We did discuss with the family that surgical intervention may be necessary if his fracture were to displace further in the cast.
