• Title: 진료templates
• Type: =
• Tags: #📝️/🌿️ #📝️/🚹/🌿
• Formation Date: 2024-03-12

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

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)