Can someone post up a routine daily progress note for some standard cases, e.g. post-op shoulder, hip, knee; post-op wash-out; clinic note s/p UE/LE fx.

Clarification of the acronyms would be helpful as well as lame as that might sound.

NVID 5/5 ehl/fhl/ta/ga
silt t/s/s/dp/sp

Thanks.

NVID = Neurovascularly intact distally

ehl = Extensor Halicus Longus
fhl = Flexor '' ''
ta = Tibialis Anterior
ga= Gastroc ?

SILT = Sensation intact to light touch
tibial/sural/saphenous/deep/superficial peroneal

ga= Gastroc ?l

should be GS for gastroc/soleus

furthermore, it seems weird to describe sensation to light touch over a nervous distribution as opposed to a dermatomal distribution because you can have foot pain arising from a pinched lumbar root... then if they have a deficit in a particular dermatomal distribution, you can further specify at which level (i.e. which nerve) the deficit arises from.

furthermore, it seems weird to describe sensation to light touch over a nervous distribution as opposed to a dermatomal distribution because you can have foot pain arising from a pinched lumbar root...

Guess you've never done an H&P on someone with LE trauma...

ga= Gastroc ?l

should be GS for gastroc/soleus

furthermore, it seems weird to describe sensation to light touch over a nervous distribution as opposed to a dermatomal distribution because you can have foot pain arising from a pinched lumbar root... then if they have a deficit in a particular dermatomal distribution, you can further specify at which level (i.e. which nerve) the deficit arises from.

You have to look at it from a clinical context. If you have a patient on the floor who just had a total hip done, or an ORIF of the acetabulum, you would be concerned with the sciatic nerve postop, not the lumbar roots. Hence the nerve distributions in the progree note. Now if the patient is a postop lumbar fusion then yes you'd be more concerned with the dermatomal distribution/functioning nerve levels.

NAD, Calm, AAOx3, atraumatic normocephalic, OP clear, trachea midline, RRR by palpation, no resp distress, no audible wheezes/stridor, no cyanosis, no tachypnea, abd nt/nd/soft, (insert ortho exam).

There is your your ortho h&p without a pair of ears.

Don't forget to auscultate the orthopaedic point on the solar plexus, where you can simultaneously detect heart, breath, and bowel sounds. Preferably using your iStethoscope iPhone app so you have your hands free to finish your note.