2012 Orthopaedics POMR Template

MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)
MBBS3003 ORTHOPAEDICS POMR

STUDENT NAME: STUDENT NUMBER:
INSTRUCTIONS:
Each student is to ask their unit registrar on the first day, either through the hospital Orthopaedic Department offices or the Orthopaedic ward, to be assigned a clinical case. The assigned case is unique to each student (i.e. no sharing). Take a history and examine the assigned patient prior to surgery. The patient must be seen preoperatively. Treatment must include surgery. You are expected to attend the operating theatre for this case only. Components of the assignment contain a word limit, marks may be deducted for exceeding 10% either side of the word limit. The completed assignment is to be submitted as an email attachment to [email protected] by 4pm on the Friday of the last day of the Orthopaedics component of your surgery rotation, but no later than Thursday of week 8 for those students doing Orthopaedics in the last two weeks of the Surgery rotation. It should be noted that one mark per day will be deducted for late submissions of your assignment and your Orthopaedic mark will not be allocated unless the assignment has been completed satisfactorily. Please ensure you have entered your name and student number in the space provided above.
__________________________ __________________________
< 30%
Fails to demonstrate most or all of the basic requirements of the course: Demonstrates clear deficiencies in understanding and applying fundamental concepts; communicates information or ideas in ways that are frequently incomplete or confusing and give little attention to the conventions of the discipline Demonstrates superficial or partial or faulty understanding of the fundamental concepts of the field of study and limited ability to apply these concepts; presents undeveloped or inappropriate or unsupported arguments; communicates information or ideas with lack of clarity and inconsistent adherence to the conventions of the discipline Demonstrates adequate understanding and application of the fundamental concepts of the field of study; develops routine arguments or decisions and provides acceptable justification; communicates information and ideas adequately in terms of the conventions of the discipline Demonstrates substantial understanding of fundamental concepts of the field of study and ability to apply these concepts in a variety of contexts; develops or adapts convincing arguments and provides coherent justification; communicates information and ideas clearly and fluently in terms of the conventions of the discipline As for Capable, with frequent evidence of high level reasoning in defining and analysing issues or problems and in creating solutions; uses a level, style and means of communication appropriate to the discipline and the audience As for Proficient, with constant evidence of high level reasoning and insight in identifying, generating and communicating competing arguments; critically evaluates problems, their
Unacceptable , very unsafe
30-39%
Rudimentary, unsafe
40-49%
Limited
50-64%
Adequate
65-74%
Capable
75-84%
Proficient
> 85%
Outstanding
Updated: 2nd December, 2011
Page 1 of 5
solutions and implications
GRADING:
The Orthopaedic POMR will receive a percentage grade in four components MARK using the guide above for each component: o Clinical Presentation o Management o Post Operative Care and Complications o Post-discharge considerations and Rehabilitation o Letter to GP (essentially a case summary)
FINAL
Patient details Initials: Sex: DOB: UR.No. 1. Briefly describe the patients history and symptoms at the time of presentation. (150 words or less)
2.
What effect has the condition had on the patients function?
3.
Using a two column format, list six (6) features (positive or negative) in the history which you consider the most relevant. Briefly outline the significance of each feature. Significance (eg) Injury causing hip pain and disability
History Feature (eg) Fell down stairs
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4.
Using a two column format, list six (6) features (positive or negative) of the clinical examination which you consider the most relevant. Briefly outline the significance of each feature.
Clinical Feature (eg) Range of elbow flexion extension 3070 degrees
Significance (eg) Marked reduction in elbow movement
5. List six (6) other features (medical, personal, social or environmental) relevant to the management of the patient. Briefly outline the significance of each issue. Other Feature (eg) House burned down at time of injury Significance (eg) Need to find accommodation when discharged
6. Using a three table format list the six (6) most important investigations which would help in making the diagnosis and the results of the investigations if done. Briefly explain the importance of each result in the making of the diagnosis or the management of the patient.
Investigation (eg) Serum rhubarb
Result (eg) = 6gms per litre abnormally elevated
Significance (eg) Evidence of rhubarb addiction
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7. What is the diagnosis?
8. List all the possible options available in the treatment of the patients condition.
9. What operative procedure was performed? The operation details are not required. In 50 words or less, justify the operation as being the most appropriate.
10. Using a three column format, list five (5) of the most common complications that might occur. What prophylactic measures can be taken to minimize the risk of each of these complications? What would be the management of each complication should it occur? (Assume the prophylactic precautions have been taken.) Do not include pain as a complication. Complication (eg)Rhubarb intoxication Prophylaxis (eg) Dietary control (exclude rhubarb) Management (eg) Dialysis
11. In the table below, list each complication which actually occurred in the management of your patient. What prophylactic measures were taken? How was the complication treated? Finally, list the outcome of the complication (eg death, paralysis-confined to a wheelchair, prolonged hospital stay with permanent morbidity etc).
Actual
Prophylactic
Definitive
Outcome of
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complication
measures taken
Treatment
complication
12. Was the final outcome from this admission satisfactory? If not, briefly explain (in 50 words or less) why.
13. At the time of discharge from hospital, list in a two column format the continuing issues in patient management and what arrangements were made to deal with these issues.
Post-discharge issue (eg) Impecunious
Management (eg) Bank loan arranged
14. What advice would you give the patient at the time of his/her discharge?
15. Summarize this case in 250 words or less in the form of a letter to the patient's GP, Dr A Butcher, 123 Care Lane, Notown, 4999 to provide the GP with sufficient knowledge and understanding of this patient's case in order that he will be able to continue effectively caring for the patient. De-identify the patient using initials only.
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2012 Orthopaedics POMR Template

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MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)

MBBS3003 ORTHOPAEDICS POMR

Unacceptable , very unsafe

Updated: 2nd December, 2011

MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)

solutions and implications

What effect has the condition had on the patients function?

History Feature (eg) Fell down stairs

Updated: 2nd December, 2011

MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)

Clinical Feature (eg) Range of elbow flexion extension 3070 degrees

Significance (eg) Marked reduction in elbow movement

Investigation (eg) Serum rhubarb

Result (eg) = 6gms per litre abnormally elevated

Significance (eg) Evidence of rhubarb addiction

Updated: 2nd December, 2011

MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)

7. What is the diagnosis?

Updated: 2nd December, 2011

MBBS3003 Orthopaedics Problem Oriented Medical Record (POMR)

Post-discharge issue (eg) Impecunious

Management (eg) Bank loan arranged

Updated: 2nd December, 2011

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