MSK8R Lab PNUH Rehabilitation

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EMR Templates

진료시 자주 사용하는 예문 관리

1 외래EMR

SOAP

S

BHx)

  • Onset : 10년전, 양산에서 tpi 로 예상되는 주사 10대는 맞은것 같은데 붓고 효과는 없었다.

S) nRS : 3, 9(마비가 있을때)

20250707 | 손발 뻣뻣한느낌이 더 심한 것 같습니다. 감상선 항진증이 수치가 올라갔습니다.

20250609 | 허리도 뻣뻣함 있음, 신경과에서 편두통 심해서 약 먹고 있습니다., 전체적인 통증 민감도 증가, 집은 좌천동, 통원치료 가능

A

가능성 높은 진단그룹 C-HIVD Osteoporosis, secondary to hyperthyroidisim -> familial Hx. (모친이 30대부터 발생)

적은 그룹 SI joint arthritis, r/o AS -> Less likely (lab 정상)

그외 및 타과 그룹 MR [2022-12-05] Reconstruction state of anterior tibiofibular ligament (ATFL) 3개월 전에 ATFL rupture 재수술

P

  • Education : Sagittal balance, exercise : Mkz_ex, pectoralis stretching

  • Med

  • 골감소증에 대해 calcium / VitD 처방

  • FM 과 통증역치 저하 등에 대해 duloxta 1달 사용 후 side/약효 평가

  • Documents

  • 진단서 - 4주 안정가료, 오래된 상병로 한번만 발급 설명

  • RTC

  • 4wks

  • 다음외래에서 모친도 갑상선항진증 등 2차성 osteoporosis아닌지 Hx

Spine

S> PHx) Onset : resting nRS : severe nRS : 방사통 : 엉치- 허벅지- 종아리- 발 Rt/Lt 방사통 : 어깻죽지- 윗팔- 아랫팔- 손 Rt/Lt 직업 : 운동 : morning stiffness:

Sitting : Lordotic_curve/ AB Sit_to_stand : Lordotic_curve/ AB

O>

  • P/Ex Percussion Td : + Shear instability : L5 severe Spurling sign :

Pain provocation : coughing/ chair_pulling/ heel_pounding Mckenzie ex. prone : 1단계 Mckenzie ex. standing : 10도

  • imaging study

A> IDD c referral pain L-HIVD c sciatica C-HIVD c radiating pain

P> ABC 1단계 education (1: Mkz ex & Spine_hygiene/ 2: TDF_bracing/ 3: Core_strengthening) NSAIDs/ PTx RTC 3wks/ Injection list up - 금요일오전, Level ( )

Shoulder

S> PHx) Onset : resting nRS : severe nRS : location: Agg factor : 직업 : 운동 :

PHx) DM : Thyroid Ds :

O) ROM test (F-A-ES-IS-ER) : - - ( ) - ( ) - Painful LOM : ER Abduction IR Provocative test : Hawkin's Neer Empty_can

Belly_press Lift_off

Speed Crank_test Spurling_sign

A) painful_stiff_shoulder, Rt/ Lt rotator_cuff_tear, Rt/ Lt calcific_tendinitis, Rt/ Lt

P) Impinge ser USG c intervention SSE_education/ close_chain_stretch_education NSAIDs PTx RTC in 3w

Knee

S) PHx) Onset : resting nRS : severe nRS : location : effusion :

PHx) DM : RA :

O) antalgic_gait : ROM(0-130) : - full_flexion_pain : flexion-rotation pain : single leg squat pain : Mcmurray test (Med/Lat) ( / ) joint line Td ( / ) knee swelling/heating sense : Pes anserine Td : ITB friction pain :

A) Knee OA c synovitis Physiologic over stree, PFPS Tendinitis - Patellar/ Pes_anserin/ ITB/ Biceps_femoris

P) knee_XR Q-setting, heel lift, tolerable walking education trast patch, NSAIDs RTC3wks/ USG(consider_injection)

2 물리치료EMR

요통환자

L0 (외래)

  1. 요추손상 증상, 원인, 치료 기본개념 설명
  2. 일상생활 동작 교육(PA) : 의자, 침대, 신발신기, 세수, 물건줍기 등

L1

lumbar 1단계

  1. Spinal stability: Lordosis posture / abdominal bracing
  2. MKz extension exercise : standing, prone (통증없는 범위)
  3. 일상생활 동작 교육

L2

  • 1단계 점검 및 교정 : Spine stability & MKz extension Lumbar 2단계 - hinge motor control and TLF strengthening
  1. Hip hinge education : Potty squat
  2. Gluteus strengthening : hip abduction (band)
  3. Latissimus strengthening : seated row (band)

L3

  • 2단계 점검 및 교정 : Hip-hinge control, hip and back exercises Lumbar 3단계 - core strengthening
  1. Bird-dog
  2. plank
  3. 개별적으로 더 진행가능한 advanced core exercise 교육

경부통환자

C0 (외래)

Cervical 0단계 - 평가 및 운동 선택

  1. 경추손상 증상, 원인, 치료 기본개념 설명
  2. 일상생활 동작 교육(PA)

C1 (PT실)

Cervical 1단계

  1. Spine sagittal balance : Lordosis posture(평시, 모니터작업), Forward Head posture 교정
  2. Round shoulder 교정 : scapular retraction, pectoralis stretching
  3. MKz extension : Standing & sitting MKz extension exercise 교육(통증없는 범위)

어깨 - 회전근개

S0 (외래)

  • Scapular stabilization exercise 소개
  • Impinge 회피 교육
  • 평가 및 운동 선택

S1

SSE 1단계 - Enhance flexibility in tolerable range

  1. Scapular Stretching : shoulder retraction standing hands clapsed & Scapular clock exercise
  2. Shoulder static passive ROM : flexion, ER -> 나머지, IR(sleeper's stretch)
  3. (if needed) joint mobilization, manual stretching

S2

SSE 2단계 - Periscapular strengthening / activiation

  • 먼저 0~1단계 점검 (impinge 회피, flexibility 평가)
  1. Scapular dips
  2. Scapular plus-up
  3. Serratus anterior activation

S3

SSE3단계 - Rotator cuff strengthening + proprioception

  • 2단계 점검 (통증 유발 조사, 잘못된 자세 교정)
  1. Blackburn (N, T, Y) or butterfly
  2. Axial loaded AROM : Wall roll, Wall ball clock.

회전근개 재활 프로그램

3 Intervention clinic

LS spine

###2018-10- Rt. L5 Transforaminal epidural space steroid injection###

Approach> transforaminal

Level> L5/S1

Needle placement>

  • L5 ~ Oblique view: subpedicular Lateral view: ventral epidural space A-P view: within neural foramen
  • S1 Oblique view: upper lateral  quadrant Lateral view: anterior to sacral margin A-P view: within posterior foramen

Contrast dispersion> mainly proximal ( both proximal and distal / mainly distal ) peri-neural

Symptom reproduction> Location: to calf ( foot / thigh etc) Characteristic: sharp (electrical shock-like)

Medication> Triamcinolone 40mg in 1ml + normal saline 3.5ml + ropivacaine 0.75% 0.5ml

RM pf. 이재현* / R3 000

4 USG clinic 🟪

줄글 형식의 판독문으로 수정할 필요도 있음. 턴체인지 되면서 develop 된 부분 반영 필요

shoulder

Intervention Hx : RP : %

@ t. shoulder USG findings> LBT : no definite abnormality SSC : no definite abnormality AC : no definite abnormality SST :  no definite abnormality IST : no definite abnormality

Abnormal findings) LBT: dislocation / subluxation / fibrillary_pattern_absent

AC : widening / degeneration

tendinosis: hypoechogenicity / heterogenicity / thickening /

tendon tear : sagging / intrasubstance_tear / articular_side_gap

Calcification : Hyperechoic_nodule_with_(no/faint)_shadowing / liquefied_nodules

Labrum : Hypoechoic cleft within post. labrum

Intervention>

  • IA injection (manual HD)

    • total 20cc, post approach
    • LBTS bulging (+), post. capsule bulging __cm / rupture (-) / post-injection soreness (mild)
    • SASD bursa leakage (+)

  • SASD bursa inj

    • Subcoracoid bursa inj
    • Subscapular bursa inj

  • Calcium barbotage

    • near clear larvage c bursa inj, syringe x 5개
    • Crushing barbotage c bursa inj

Care plan> RTC 3 wks NSAIDs for 3days

knee

Intervention Hx : RP : %

@ t. knee USG findings> Ant : Sup patellar effusion: mm Med : meniscus : MCL : Pes anserine : Lat : meniscus : MCL : ITB : Post :  baker_cyst : otherwies no_definite_abnormality

%%Abnormal findings 필요한 것 옮겨적고 삭제%% synovial_hyperplasia / heterogenic_patellar_tendon meniscal_protrusion / osteophyte effusion baker_cyst

Intervention>

  • IA injection
    • total 10cc, tam1@, lat. approach
      • with aspiration : 20cc
    • synovian inj
  • MCL_bursitis/ ITB_bursitis/ Pes_anserine inj

Care plan>

  • NSAIDs for 3days
  • RTC 3 wks

1. Shoulder

  • Anterior

    • Long biceps tendon sheath: No effusion
    • Subscapularis tendon: Normal echotexture and thickness, no tears or calcification.
    • Coracobrachial bursa : No significant fluid or thickening.

  • Superior / Modified Crass position

    • Acromioclavicular joint: No definite abnormality
    • Supraspinatus tendon: Normal echotexture and thickness, no tears or calcification.
    • Subacromial-subdeltoid bursa: No significant fluid or thickening.

  • Posterior

    • Infraspinatus and teres minor tendons: Normal echotexture and thickness, no tears or calcification.
    • No labral abnormality.

Abnormal Findings Vocabulary

slight / mild / moderate / severe

  • Tendons

    • fibrillar_pattern_defect / sagging / articular_side_gap
    • Hypoechoic_thickening / Heterogenic_echogenicity (tendinosis)
    • Cortical_irregularity
    • Calcification / linear_calcific_metaplasia / enthesophyte
    • Discontinuity or retraction

  • Bursa

    • Subacromial-subdeltoid bursa : thickened_walls / fluid_distension, synovial_hypertrophy / teardrop_sign

  • Joint

    • Joint_space_narrowing
    • Hyperechogenic capsule
    • Synovial hypertrophy
    • Labral detachment / hypoechoic_cleft

  • Dynamic Findings

    • Impingement during abduction
    • Subluxation or dislocation of biceps tendon

2. Elbow

  • Anterior: Biceps tendon is intact without evidence of tear or tenosynovitis.
    • no joint effusion
  • Lateral: Common extensor tendon and radial collateral ligament are normal.
  • Medial: Common flexor tendon and ulnar collateral ligament are intact.
    • Ulnar nerve : normal caliber and no subluxation
  • Posterior: Triceps tendon is intact, and olecranon bursa shows no effusion.

3. Wrist

@ t. volar wrist USG

  • The median nerve is normal within the carpal tunnel.
    • Caliber at tunnel : within_normal_limit
  • Flexor tendons show normal echotexture without tenosynovitis.

@ t. dorsal wrist USG Tendons : 1st to 6th compartments of extensor tendons are intact, with normal echogenicity and no sheath thickening or fluid collection Radiocarpal and Midcarpal Joints:

  • Joint spaces are clear, with no effusion or synovial hypertrophy.
  • No evidence of cartilage irregularity, osteophytes, or loose bodies.

1st Compartment (Abductor Pollicis Longus and Extensor Pollicis Brevis):

  • Tendons are intact, with normal echogenicity and no sheath thickening or fluid collection

2nd Compartment (Extensor Carpi Radialis Longus and Brevis):
3rd Compartment (Extensor Pollicis Longus):
4th Compartment (Extensor Digitorum Communis and Extensor Indicis):
5th Compartment (Extensor Digiti Minimi):
6th Compartment (Extensor Digiti Minimi):

Abnormal Findings Vocabulary

  • Nerves : enlarged / hour_glass_appearance
  • Tenosynovitis: Thickened synovial sheath with increased vascularity.

4. Hand

  • Volar finger: Flexor tendons and volar plates are intact without abnormal findings.
  • Dorsal finger: Extensor tendons are normal.
  • Joints : All MCP and CMC joints are unremarkable.

Abnormal Findings Vocabulary

5. Hip

  • Anterior

    • Iliopsoas tendon and bursa: No effusion or bursitis.
    • Hip joint anterior recess: Normal, no fluid collection.
    • Rectus femoris : Normal echotexture and thickness, no tears or calcification.

  • Lateral

    • Gluteus medius and minimus tendons: Normal echotexture and thickness, no tears or calcification.
    • Trochanteric bursa: No significant fluid or thickening.

  • Posterior

    • Gluteus maximus muscle: Intact.
    • Sciatic nerve: Normal caliber and position.

  • Medial

    • Adductor tendons: Normal echotexture and thickness, no tears or calcification.

6. Knee

  • Anterior: Quadriceps and patellar tendons are normal
    • Suprapatellar bursa : slight synovial fluid within normal limit
  • Medial: Medial collateral ligament and pes anserine bursa show no abnormalities.
  • Lateral: Lateral collateral ligament and iliotibial band appear normal.
  • Posterior: Popliteal fossa and gastrocnemius-semimembranosus bursa are unremarkable.

Abnormal Findings Vocabulary

mild / moderate / severe

  • Effusion: effusion / pes_anserine_bursa_effusion
  • osteophyte_protrusion / meniscus_protrusion / meniscofemoral/meniscotibial_synovium_thickening
  • Calcification: calcification detected in / enthesophyte

7. Ankle

  • Anterior: Tibialis anterior tendon and tibiotalar joint are normal.
  • Posterior: Achilles tendon is intact without signs of tendinosis.
  • Lateral: Anterior talofibular ligament (ATFL) are normal
    • Peroneal tendons and calcaneofibular ligament appear normal.
  • Medial: Tibialis posterior tendon and deltoid ligament are intact.

8. Foot

  • Dorsal: Extensor tendons and metatarsophalangeal joints are unremarkable.
  • Volar: Plantar fascia is normal without thickening.
    • medial calaneal Td (-)
  • Lateral: Peroneus longus and brevis tendons: Intact.
  • Medial: Abductor hallucis muscle and navicular bone are normal.

9. Brachial Plexus

  • Interscalene region

    • C5, C6, C7 nerve roots: Normal echotexture and caliber, no mass-like lesions.
    • Scalene muscles: Normal thickness, no hypertrophy or masses.

  • Supraclavicular region

    • Superior trunks: Normal echogenicity, no space-occupying lesions.
    • Subclavian artery and vein: Normal appearance.

  • Infraclavicular region

    • cords: Normal morphology, no thickening or abnormal hypoechoic areas.

Common Diseases by Body Region and Ultrasound Findings

1. Shoulder

  • Joint

    • Painful stiff shoulder (frozen shoulder)
    • Glenohumeral joint arthritis

  • Rotator Cuff Pathology

    • Rotator cuff tear (partial_thickness / full_thickness)
    • Rotator cuff tendinosis
    • Calcific tendinitis

  • Bursa

    • Subacromial-subdeltoid bursitis
    • Subcoracoid bursitis

  • Dynamic Abnormalities

    • Shoulder impingement syndrome
    • Biceps tendon subluxation/dislocation

2. Elbow

  • Tendon Pathology

    • Lateral epicondylitis ("tennis elbow")
    • Medial epicondylitis ("golfer's elbow")
    • Triceps or biceps tendon rupture

  • Bursa

    • Olecranon bursitis

  • Ligament and Nerve

    • Ulnar collateral ligament sprain or tear
    • Cubital tunnel syndrome (ulnar nerve compression)

3. Wrist

  • Nerve

    • Carpal tunnel syndrome (median nerve entrapment)
    • Guyon's canal syndrome (ulnar nerve compression)

  • Tendon Pathology

    • Flexor tenosynovitis (trigger finger, De Quervain's tenosynovitis)
    • Extensor tendon injury

  • Soft Tissue

    • Ganglion cyst
    • Foreign body granuloma

4. Hand

  • Tendon Pathology

    • Trigger finger
    • Flexor or extensor tenosynovitis

  • Joint Pathology

    • Osteoarthritis (joint space narrowing and osteophytes)
    • Synovitis / Rheumatoid arthritis (synovial hypertrophy and joint effusion)

  • Soft Tissue

    • Soft tissue masses (lipoma, cyst)
    • Foreign body

5. Hip

  • Tendon Pathology

    • Gluteus medius/minimus tendinosis or tear
    • Iliopsoas tendinosis

  • Bursa

    • Trochanteric bursitis
    • Iliopsoas bursitis

  • Joint

    • Hip joint effusion (septic arthritis, osteoarthritis)
    • Labral tear

  • Nerve

    • Sciatic nerve compression (piriformis syndrome)

6. Knee

  • Tendon Pathology

    • Quadriceps or patellar tendinitis/tendinosis
    • Tendon rupture (partial or complete)

  • Ligament Pathology

    • Medial or lateral collateral ligament sprain or tear
    • Anterior or posterior cruciate ligament tear (not fully assessed by USG)

  • Bursa

    • Pes anserine bursitis
    • Baker’s cyst

  • Joint Pathology

    • Knee effusion (trauma, arthritis, infection)
    • Meniscal cyst (limited USG use for meniscal tears)

7. Ankle

  • Ligament Pathology

    • Anterior talofibular ligament (ATFL) sprain or tear
    • Deltoid ligament sprain or tear

  • Tendon Pathology

    • Achilles tendinosis or tear
    • Peroneal tenosynovitis

  • Joint

    • Ankle effusion (arthritis, trauma)
    • Sinus tarsi

  • Bursa

    • Retrocalcaneal bursitis

8. Foot

  • Tendon Pathology

    • Plantar fasciitis (fascia thickening at calcaneal attachment)
    • Extensor tenosynovitis

  • Soft Tissue Pathology

    • Morton’s neuroma
    • Ganglion cyst

  • Joint Pathology

    • Metatarsophalangeal joint effusion (inflammatory arthritis, gout)

9. Brachial Plexus

  • Nerve Pathology

    • Brachial plexopathy (trauma, tumor, or radiation-induced)
    • Nerve root avulsion (traumatic injury)
    • Neuropathy (e.g., neuritis, compressive neuropathy)

  • Surrounding Structures

    • Schwannoma, neuroma, or metastatic lesion
    • Vascular compression or thrombosis (subclavian artery/vein)
    • Scalene muscle hypertrophy or mass (e.g., thoracic outlet syndrome)