medical report example for patient with scoliosis

Patient report example : Scoliosis Patient report example : Scoliosis 14 year-old female. Right thoracic idiopathic scoliosis.

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What should be included in a physical exam for scoliosis?

PHYSICAL EXAMINATION The scoliosis patient’s physical examination should begin with the overall appearance, the skin and the neuromuscular system before the evaluation of the back’s shape (Table 2). A height measurement is important to monitor skeletal growth and the risk of scoliotic curve progression.

Which tests are used in the evaluation of pediatric scoliosis?

Grossman TW, Mazur JM, Cummings RJ. An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting. J Pediatric Orthop.

What are the imaging options for scoliosis and back pain?

Further imaging for patients with scoliosis and back pain may include a bone scan or a magnetic resonance imaging (MRI) test. These imaging modalities are beyond screening examinations and are usually obtained by the treating surgeons.

What is scoliosis and how is it treated?

Scoliosis is a lateral curving of the spine with the thoracic area being the most commonly affected. It can be classified as functional or structural. Functional scoliosis is the result of another deformity and is corrected by treating the underlying problem.

How do you document scoliosis?

An X-ray will show the spine from the front and back of the body, clearly revealing its shape and whether there is a curve. This can confirm the presence of scoliosis. A doctor will then use the X-ray to calculate the Cobb angle measurement, which tells whether the curve is mild or severe.

How would you describe scoliosis radiology?

Summary. Scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more. The Cobb angle is measured between the superior endplate of the proximal end vertebra and the inferior endplate of the distal end vertebra.

How do you assess scoliosis patient?

Scoliosis is usually confirmed through a physical examination, an x-ray, spinal radiograph, CT scan or MRI. The curve is measured by the Cobb Method and is diagnosed in terms of severity by the number of degrees.

What are the 3 types of scoliosis?

Most experts feel there are three categories of scoliosis. idiopathic, congenital, and neuromuscular. Idiopathic is the most common type of scoliosis. This means that the cause is unknown or that there is no single factor that contributes to the development of the disease.

How would you describe scoliosis?

Scoliosis is a sideways curvature of the spine. Scoliosis is a sideways curvature of the spine that most often is diagnosed in adolescents. While scoliosis can occur in people with conditions such as cerebral palsy and muscular dystrophy, the cause of most childhood scoliosis is unknown.

What is a scoliosis survey?

Brief Summary: This is a survey to help understand the influences related to the decision for Adolescent Idiopathic Scoliosis treatment (observation vs. bracing vs. surgery). The investigator then plans to create a decision aid to help families when making a decision about the treatment choice being presented to them.

What is scoliosis PDF?

Scoliosis is defined as a lateral curve of the spine whit fixed rotation and. permanent deformation of the vertebrae. More precisely, scoliosis is a. deformity of the spine in all three space's planes: frontal plane (lateral. curvature), horizontal plane (rotation of the vertebrae) and sagittal plane.

How do you diagnose scoliosis at home?

0:101:31How to Detect Scoliosis at Home | Explained Under 1 minute - YouTubeYouTubeStart of suggested clipEnd of suggested clipSeveral things to look for when screening for scoliosis. Include one head appears off centeredMoreSeveral things to look for when screening for scoliosis. Include one head appears off centered between the hips. To one shoulder appears higher than the other.

What is the main cause of scoliosis?

In more than 80 percent of cases, the cause of scoliosis is unknown — a condition called idiopathic scoliosis. In other cases, scoliosis may develop as a result of degeneration of the spinal discs, as seen with arthritis, osteoporosis or as a hereditary condition that tends to run in families.

What are 4 symptoms of scoliosis?

In adults, scoliosis causes symptoms like these:Uneven shoulders and/or hips.Bump in the lower back.Numbness, weakness, or pain in the legs.Trouble walking.Trouble standing up straight.Tired feeling.Shortness of breath.Loss of height.More items...•

What is another name for scoliosis?

Levoscoliosis is a kind of scoliosis where your spine twists and curves toward the left side of your body in a C shape.

What problems can scoliosis cause?

In particularly severe cases of scoliosis the ribcage can be pushed against the heart and lungs, causing breathing problems and making it difficult for the heart to pump blood around the body. This can also increase the chances of lung infections, such as pneumonia, and lead to problems such as heart failure.

How to check for scoliosis?

When examining the back of a patient with suspected scoliosis, the evaluator should inspect the shoulders and hips for asymmetry. Significant leg length discrepancies, quickly judged by feeling the top of the iliac crests or the level of the dimples made by the posterior-superior iliac spines, can cause an oblique spinal take-off from the pelvis, which results in spinal curvature. The classic screening test for scoliosis, the forward bending test, is finally performed by having the patient bend forward at the waist with knees straight and palms together (Figure 1) (1,8). The examiner should look for any asymmetry in the contours of the back resulting from the rotational deformity of the spine (9). In classic thoracic scoliosis with the apex of the curve to the right, the patient’s right side is prominent. While this is most easily seen in the thoracic spine, it is important to look in the lumbar region for prominence as well. The inability to perform this test due to pain in the back or hamstring tightness can suggest other pathology, including mechanical back pain, disc herniation, spondylolysis or infection.

What is scoliosis on a radiograph?

Scoliosis is defined as a deviation of the normal vertical line of the spine, consisting of a lateral curvature with rotation of the vertebrae within the curve. Typically, for scoliosis to be considered, there should be at least 10° of spinal angulation on the posterior-anterior radiograph associated with vertebral rotation (1). The causes of scoliosis vary and are classified broadly as congenital, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons. Congenital scoliosis is due to a vertebral abnormality causing the mechanical deviation of the normal spinal alignment. Scoliosis can be due to neurological conditions (eg, cerebral palsy or paralysis), muscular abnormalities (eg, Duchenne muscular dystrophy) or other syndromes (eg, Marfan syndrome and neurofibromatosis). Occasionally, significant lateral deviation of the spine can occur with little or no rotation of the spine and without bony abnormalities. In these cases, the ‘scoliosis’ can be the result of pain, spinal cord abnormalities, tumours (both intraspinal and extraspinal) and infection. The majority of scoliosis cases encountered by the general practitioner will be without an obvious cause (idiopathic), and will be the main focus of the present review. The natural history relates to the etiology and age at presentation, and usually dictates the treatment. However, it is the patient’s history, physical examination and radiographs that are critical in the initial evaluation of scoliosis and in determining which patients need additional evaluation and consideration.

How to monitor scoliosis curve progression?

The most reliable method of monitoring growth is simple height measurements. Therefore, the primary physician often possesses this information from their annual examinations. Furthermore, it is important to look at other markers of growth and maturity, including signs of puberty, onset of menarche and breast development.

What age should a child be screened for scoliosis?

The Scoliosis Research Society (USA) recommends annual screening of all children between 10 and 14 years of age (37). The American Academy of Pediatrics has recommended screening with the forward bending test at routine health supervision visits at 10, 12, 14 and 16 years of age (38). Meanwhile, the US Preventive Services Task Force (39) and the Canadian Task Force on the Periodic Health Examination (40) concluded that there was insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis. The US Preventive Services Task Force concluded that the harms of screening adolescents for idiopathic scoliosis may exceed potential benefits (39). Most jurisdictions have abandoned routine screening.

What is lateral radiograph of spine?

If back pain is present, a lateral radiograph of the spine including the lumbosacral region should be obtained to look for vertebral abnormalities associated with diagnoses such as spondylolysis (an idiopathic fracture of the posterior elements of the vertebral body), spondylolisthesis (a slipping forward of one vertebral body on the adjacent one), infection or bony destruction. Further imaging for patients with scoliosis and back pain may include a bone scan or a magnetic resonance imaging (MRI) test. These imaging modalities are beyond screening examinations and are usually obtained by the treating surgeons.

What is congenital scoliosis?

Congenital scoliosis is due to skeletal abnormalities of the spine that are present at birth. These anomalies, which can include multiple levels, are the result of and broadly classified as a failure of formation or a failure of segmentation (or both) during vertebral development (Figure 2). Because these spinal deformities are present in utero, they are often first identified on fetal ultrasound (12). Organ systems that develop at the same gestational time (fifth to sixth week) may also demonstrate abnormalities in up to 60% of cases (13,14). Thus, it is important to identify associated anomalies with a thorough evaluation of the neurological, cardiovascular and genitourinary system, including a good neurological and cardiac physical examination, an abdominal ultrasound and an echocardiogram. Treatment is based on the age of the patient, progression of the curve, and the location and type of anomaly. The options for surgical treatment include in situ fusion and resection with correction of the deformity.

What is the most outward manifestation of spinal curvature?

Whether identified by the patient, their parents, or through school or physician screening programs, posterior chest wall prominence is the most outward manifestation of spinal curvature. With more significant scoliosis, adolescent girls sometimes notice a difference in their breast sizes. Other body characteristics may include shoulder asymmetry and overall posture imbalance in the coronal plane.

Who is the author of Stopping Scoliosis?

To find out more about this spinal abnormality, we asked Nancy Schommer, author of Stopping Scoliosis, to interview Dr. Ronald Moskovich, who is Assistant Professor of Orthopedic Surgery at New York University ...

How many states require spinal curvatures?

As many of our readers know, the Scoliosis Research Society, the American Academy of Orthopaedic Surgeons, and over 23 states suggest or require school screening for abnormal spinal curvatures.

What is rib thoracoplasty?

Every year, the National Scoliosis Foundation receives queries about rib thoracoplasty, a surgical technique sometimes used to help patients with scoliosis who also suffer from a "rib hump".

Can scoliosis be treated with exercise?

Exercise and Adults with Scoliosis. Many adults with scoliosis, including those with prior corrective surgery, are curious about the risks and benefits of exercises and sports participation. In our experiences, most adults with scoliosis have never held discussions with medical professionals about these issues.

What should be documented in a patient's medical report?

One thing that a doctor should have documented in the patient medical report is the medical diagnosis that he has found in the patient. Whatever disease that a patient has should be clearly stated in the medical report. The name of the disease should be clearly written and some explanations about the current condition of the patient.

What is a Patient Medical Report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has. It has the complete diagnosis on the patient, clearly stating the disease that should be treated. Through a patient medical report, anyone can analyze the health condition of a person. It sometimes contain a patient chart where the demographic profile of the patient is introduced. All types of medical records need a medical report. Patient medical records are simple data about the patient while a patient medical report is more elaborate and comprehensive. Though the importance of medical records and the purpose of medical records are almost the same with a patient medical report, the patient medical report is more beneficial. It has a complete summary of the diagnosis on the patient and have some recommendations for the health of the patient.

Why should a patient's medical report include lab results?

It is also needed because sometimes the laboratory and the test results are the proof of the sickness of the patient. For example, if the patient has a blood cancer, it can be seen with the blood tests. If the patient has a brain tumor, it can be seen through a brain CT scan. A CT scan for the body can also tell whether we have a fracture or not.

Why should medication be documented in a medical report?

The treatments or medications should also be documented because it can provide a good information about the medical history of a patient. Put the names of the medicines and tell how often did the patient takes it. You can also document its effect and tell whether it is effective for them.

Is a medical report a legal document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.

Do health care providers have access to patient medical records?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report. It can be a proof if there is any doctor withholding treatments. So, to avoid conflict, the patient medical report should be shown to the patients. HIPAA (Health Insurance Portability and Accountability Act) has been passed in the Congress of United States. Passed in 1996, it specifies who can have an access to all the health information. You can research for that law, so you can have the exact details to who can have an access to a patient medical report. It is better because you can have a legal source. It can tell you all the things that you need to know about it.

What information is included in a medical report?

Among the numerous inclusions would be: possible allergies, vaccinations, current medical evaluation, health issues, family or personal medical history, and more.

What are the different kinds of medical reports?

For some of the more in-depth and extensive examples, the different kinds of medical reports often include radiology reports, printable laboratory reports, and pathology reports.

What Is a Medical Report?

From the name itself, a medical report is a written report that usually contains the results of a medical examination conducted on a patient. It describes or outlines the findings of a medical professional, along with any suggestions for the patient’s treatment and recovery. Also referred to as a medical report letter, there’s lots more to learn about this, including how to write a medical report letter, which we will be tackling shortly.

How does a medical report differ from a prescription?

A medical report tends to be all-encompassing, complete with details of a patient’s illness and even prescriptions. If you’re just talking about prescriptions as a stand-alone document, then the details are much sparser, with only the doctor’s prescribed treatments and some of the patient’s personal details written on it.

Why is it important to use professional language in medical reports?

Use professional language and ensure that there is enough clarity to prevent any misunderstandings among all of the involved parties.

Why is it important to draw up a timeline of a patient's symptoms?

Doing so will help guide other professionals who may be assisting the patient with his or her treatment. When writing up a timeline, stick to chronological order and make it as easy to understand as possible.

Is a medical report vague?

A medical report that comes off as vague is practically useless. For it to be valid and useful, the medical professional writing it must go into detail. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient.

What are the goals of a pediatric scoliosis nurse?

Nursing care planning goals for a pediatric client with scoliosis may include restoration of normal breathing pattern, relief of pain, improved physical mobility, enhanced learning, stop the progression of the curve and prevent deformity.

When does scoliosis occur?

The deformity may occur at any age, from infancy through adolescence, but the best prognosis belongs to those who are almost fully grown and whose curvature is of a mild degree. Idiopathic scoliosis most commonly occurs in adolescent girls.

What is structural scoliosis?

Structural scoliosis is more progressive and causes changes in supporting structures, such as the ribs. Management includes observation, bracing, and surgical fusion. Patients with idiopathic curves of less than 25 degrees are observed for progress until they have reached skeletal maturity.

How often should you assess respiratory status?

Assess respiratory status every 4 hours. Scoliosis hinders the movement of the ribs, therefore weakens the respiratory muscles causing an increase in the work of breathing during, rest, activity or at sleep. Auscultate breath sounds at least every 4 hours. This is to detect decreased or adventitious breath sounds.

Is scoliosis a structural condition?

Scoliosis is a lateral curving of the spine with the thoracic area being the most commonly affected. It can be classified as functional or structural. Functional scoliosis is the result of another deformity and is corrected by treating the underlying problem. Structural scoliosis is most often idiopathic although it may be congenital or secondary to another disorder. There is a growing body of evidence that idiopathic scoliosis is probably genetic but the etiology is not completely understood. Structural scoliosis is more progressive and causes changes in supporting structures, such as the ribs. Management includes observation, bracing, and surgical fusion. Patients with idiopathic curves of less than 25 degrees are observed for progress until they have reached skeletal maturity. Bracing is recommended for adolescents with curves between 30 and 45 degrees, while curves greater than 45 degrees usually require surgery. The deformity may occur at any age, from infancy through adolescence, but the best prognosis belongs to those who are almost fully grown and whose curvature is of a mild degree. Idiopathic scoliosis most commonly occurs in adolescent girls.