sample medical report of a patient with scoliosis

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

Full Answer

What is the primary diagnosis for scoliosis?

Scoliosis with a primary diagnosis (nonidiopathic) must be recognized by the physician to identify the causes, which may require intervention. Patients with congenital scoliosis must be evaluated for cardiac and renal abnormalities. School screening for scoliosis is controversial and is falling out of favour.

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.

How do you know if scoliosis is nonidiopathic?

Young age at onset (younger than 10 years of age), rapid curve progression and the presence of neurological symptoms are the most useful findings in identifying nonidiopathic scoliosis (1). Fortunately, most frontline physicians will only encounter idiopathic scoliosis during their careers.

What is the management of scoliosis in nursing?

Management includes observation, bracing, and surgical fusion. ... 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.

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 a scoliosis curve on a physical exam?

The patient stands and bends forward at the waist, with the examiner assessing for symmetry of the back from behind and beside the patient. Patients with possible scoliosis will have a lateral bending of the spine, but the curve will cause spinal rotation and eventually a rib hump, which is visible on examination.

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.

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 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.

What is a normal finding in scoliosis test?

These images can be used to accurately measure the degree of your backbone's curve. Your doctor will tell you that you have scoliosis if your curve is greater than 10 degrees. Doctors classify angles of 25 to 35 degrees as significant, while those that are more than 50 degrees are severe.

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 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 does scoliosis affect the body?

Severe scoliosis (80+degrees) can potentially affect not only the spine and rib cage, but also, may eventually affect the heart, lungs, and other internal organs. Children with severe scoliosis frequently use compensating postures in an attempt to alleviate pain and the imbalance they feel in their body.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physic...

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patien...

Is a Patient 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 patie...

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.

What You Should Include in a Patient Medical Report

A patient medical report has some important elements that you should not forget. Include all these things and you can learn how to write a patient medical report.

Importance of a Patient Medical Report

The reason why a patient medical report is always given is because it is important. Here, you can know some of the importance of a patient medical report:

How to Write a Good Patient Medical Report

A doctor is a doctor. They are not writers. They can be caught in a difficulty on how to write a patient medical report. If this is the case, turn to this article and use these steps in making a patient medical report.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physicians, nurses, and doctors of medicine. It also includes the psychiatrists, pharmacists, midwives and other employees in the allied health.

Who Can Have Access to a Patient Medical Report?

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.

Is a Patient 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.

What are the different types of medical reports?

Types of Medical Report Templates 1 Patient Medical Report Example – This is what you need if you’re looking for a generic medical report template. This medical report targets any patient with certain illnesses, ideal for clinic or hospital use. This contains needed information such as patient’s complete name, address, contact details, questions about medical status/history, and other related medical questions. 2 Hospital Medical Report Template – This type of medical report is designed for hospital use. Information includes patient’s name, ward, hospital name, medical consultant, discharge summary, the reason for admission and medical diagnosis, and past medical history. 3 Medical Examination Report Example – If you’re making medical reports intended for medical examinations, perhaps you might want to download this template for more convenience. This is a complete template that targets examination reports in a medical setting. 4 Medical Incident Report Template – This type of medical report focuses on any incident or accident that may happen within a medical setting. This is filled so that recording of details about incidents that occur at the medical facility will be tracked down and certain measures or sanctions will be implemented. 5 Medical Fitness Report Template – Making medical reports for fitness progress? This template is what you need. This aims at providing a thorough and complete report for medical fitness. The template contains information such as applicant’s name, address, license number, name of the hospital/clinic who conducted the report, and questions related to medical fitness.

What should be written down in a medical history?

Effects of alcohol, intellectual, emotional, psychiatric, and other drugs taken should be written down. Regardless if there are negative findings, it should also be included. Medical History. When writing a patient’s medical history, relevant medical conditions should be considered.

Why is it important to update medical reports?

In every patient’s life, change always comes, may it be a changed name, address, medical progress, or a new health diagnosis and prescription.

What are some examples 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.

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.

Can you keep a copy of a medical report?

The creation of a medical report may dictate that you keep a separate but identical copy for yourself. The purpose of doing so is purely related to documentation. Also, in the event that the original medical report is somehow lost or tampered with, the patient can always turn back to you for references.

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.

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.

What are the goals of a nursing care plan for a pediatric client with scoliosis?

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. Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for scoliosis:

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.