Patient Note (Kirstie)
Kirstie
(Patient ID 020)
| Name: Kirstie | Age: 54 | Surgery date: 8 weeks ago | MR #: 000-020 |
| Gender Identity: Female | Race: Caucasian |
Admitting diagnosis: Distal Radial Fracture |
Insurance: BCBS |
| History of present illness: Kirstie is a 54-year-old female who experienced a distal radial fracture of her R dominate wrist after a fall in her home. She underwent ORIF procedure with placement of internal fixator using screws. | |
|
Past medical/surgical history: Arthritis GERD |
| Social History: Kirstie is married and lives with her husband. She enjoys cooking and making necklaces for her family and two granddaughters. | |
| Employment/work/school: Full time office manager | |
| Prior level of function: Kirstie reports that she is the primary housekeeper in her home (i.e., laundry, dishes, cooking, cleaning). She performed all work and home responsibilities independently with no modifications prior to her injury. |
Apply soft splint to R wrist for support
OT eval/treat 8 weeks post-op
Diclofenac gel
Meloxicam
Pepcid
Multivitamin
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.