DR SURESH KUMAR J HARIHARAN

MBBS (India), MS (Ortho)(UKM)

Consultant Orthopaedic & Trauma Surgeon
Orthopaedic Specialist Clinic, c/o ANOC Neuroscience and Orthopaedic Centre,
2nd Floor, Menara BRDB,285 Jalan Maarof, Bukit Bandaraya, 59000 Kuala Lumpur
___________________________________________________________________

Your ref :
Our ref : MRN
Date : th July 2018

To:

SPECIALIST MEDICAL REPORT

NAME :

NRIC :

AGE : years

SEX : Male / Female

MARITAL STATUS : Married / Single

DOMINANT HAND : Right / Left

OCCUPATION BEFORE ACCIDENT :

OCCUPATION AFTER ACCIDENT :

LEVEL OF EDUCATION :

DATE OF ACCIDENT :

DATE OF EXAMINATION : th July 2018

TIME LOSS FROM WORK :

Documents made available:
1) Orthopaedic Medical Report from Hospital………………..dated………..

2) Emergency Department Medical Report from Hospital……………….

dated………..

3)……………….Medical Report from Hospital………………..dated………..

HISTORY & DIAGNOSIS

This patient was involved in an alleged motor vehicle accident on the …………….
He/She was admitted to Hospital…………… …….. on the same day.

It was reported he/she sustained the following injuries:

1)

Patient also mentioned he/she sustained …………………...

This was not mentioned in the initial medical report from Hospital ………….... Kindly
get verification from the hospital.

TREATMENT GIVEN:
Patient was treated in Hospital………………....
Definitive management was in Hospital………………………..
Fracture right/left ……….. was operatively reduced and internally fixed with
…………….. on ………../2017.
Analgesic and antibiotic administered.
Discharged from hospital on …………….

Patient was seen in my clinic on th July 2018 for the purpose of Orthopaedic
Specialist Medical Report. For other associated injuries please refer to respective
Specialist Medical Report.
PRESENT STATUS & COMPLAINTS
Although patient had returned to his/her work as ………………, he/she still
continues to suffer from the consequences of the accident in the form of
…………………. pain, stiffness and weakness.
As a ……………… he/she is expected to …………….. and ………………, which
he/she finds difficult / can’t perform now
Patient is currently unemployed due to the disability arising from trauma sustained
from the accident.
As a result of accident patient also complaints of the following:
1) Work related:
i. He/She is unable to stand longer than 30 minutes at a time,
when previously he/she could stand up to 3 hours
ii. Walking distance he/she cannot exceed 500 meters at a time
when before the accident he/she could walk up to 5 km. His/Her
work involves lot of movement.
iii. His/Her walking speed has declined by 50%.
iv. He/She is also slow in getting up from sitting position and needs
assistance of upper limb to support him/her.
v. Climbing stairs is difficult and slow, that too using opposite lower
limb first.
vi. Cannot walk while carrying heavy objects.
vii. Unable to lift heavy objects with right/left upper limb.
viii. Impaired dexterity in right/left wrist.
ix. Use of keyboard slower by more than 50 percent.
x. Hand writing has changed for worse.
xi. Unable to feed himself with his/her hand when eating, needed to
use spoon to reach his mouth.
xii. Pain in the right/left shoulder on manoeuvring the steering and
engaging the gear while driving.
xiii. When riding motorcycle, turning the throttle is difficult.
xiv. Early hand fatigue
xv. Poor grip strength. Unable to open tight bottle caps.
xvi. Unable to carry load on shoulder when climbing ladder.
xvii. difficult to hold and climb ladder
xviii. unable to crawl on in tight spaces due to pain in right shoulder

2) Activities of daily living:

i. Unable to perform Muslim prayer in customary manner. He/She
needs to use chair to sit.
ii. Unable to squat, need toilet modification to sitting type.
iii. Unable to sit cross legged.
iv. Unable to drive his/her car as he/she is not confident of stepping
on brakes in an emergency.
 v. Unable to ride motorcycle because
vi. Overhead activity such as combing hair is difficult
vii. Unable to use right/left hand to scrub his/her back.
viii. Cooking
ix. Washing
x. Wearing and removing T-Shirt is difficult.

3) Leisure and sports:

i. He/She loves to play futsal, football, badminton and hiking. All
those activities are behind him/her, after the accident.
ii. He/She loves to play football, but it is behind him/her since after
the accident.

4) At rest and sleep:

i. He/She gets pain in right/left …… when exposed to cold
weather or on a rainy day.
ii. On sleeping to his/her right/left, he/she gets pain in right/left…..
at …….area.

EXAMINATION
Patient is of………………….. built. He/She was comfortable and cooperative
throughout examination.
Clinically pink.
Cardio vascular system : Dual rhythm, no murmur noted
Respiratory system : Air entry equal bilateral
Abdomen : Soft, Nothing Abnormal Detected (NAD)
Upper/ lower limb function is normal.
UPPER LIMB EXAMINATION
SCARS
• No obvious scar visible in right/left upper limb from this injury.

APPEARANCE OF LIMB/ DEFORMITY

• No obvious external deformity noted in right/left upper limb.

JOINTS RANGE OF MOTION (in degrees) Right Left

Shoulder

Flexion 0- ° 0- °

Extension 0- ° 0- °

Abduction 0- ° 0- °

Adduction 0- ° 0- °

Internal Rotation 0- ° 0- °

External Rotation 0- ° 0- °
Impression: Range of motion in both shoulders are equal. Range of
motion in right/left shoulder is impaired.

Elbow

Flexion Extension 0- ° 0- °
Impression: Range of motion in both elbows are equal. Range of motion
in right/left elbow is impaired.

Forearm
Supination 0- ° 0- °

Pronation 0- ° 0- °
Impression: Range of motion in both forearms are equal. Range of
motion in right/left forearm is impaired.
 Right Left
Wrist

Palmar Flexion 0- ° 0- °

Dorsiflexion 0- ° 0- °

Radial Deviation 0- ° 0- °

Ulnar Deviation 0- ° 0- °
Impression: Range of motion in both wrists are equal. Range of
motion in right/left wrist is impaired.

Range of CMCJ MCPJ PIPJ/IPJ DIPJ

Motion
( in degree )
Thumb
Index
Middle
Ring
Little
Digits Abd /add -
Thumb Abd/add -

MUSCLE WASTING (girth in centimeters)

Arm (girth in centimeters) cm cm
Forearm (girth in centimeters) cm cm
Impression: There is muscle wasting of …cm in right/left arm
and …..cm in right/left forearm.

THENAR/HYPOTHENAR NAD? NAD?

HAND GRIP good? good?
PINCH FUNCTION good? good?
NEUROVASCULAR INJURY NAD NAD
OTHER IMPORTANT FINDINGS
RADIOLOGICAL FINDINGS
Latest x-ray done on …………….. reveal fracture…………… has united and plate is
in situ.
IMPRESSION ON UPPER LIMB
Fracture has
Deformity
Muscle wasting
Grip strength and pinch function
Range of motion
Scar / Other relevant findings
LOWER LIMB EXAMINATIONS

Patient walks independently with antalgic gait.

He/She is unable to squat, but able to walk tip toe and stand on one leg on
affected side.

SCARS: There is a …..cm hyperpigmented surgical scar on ………………………

and another hyperpigmented scar …………………………measuring ….cm by
…..cm.(see picture) No visible scars in right/left lower limb from this injury.
 There are multiple surgical scars on lateral side of right/left …….. measuring ..
cm, … cm, …cm and … cm from proximal to distal, due to interlocking nail
insertion. (see picture)

APPEARANCE OF LIMB / DEFORMITY:

 No obvious external deformity noted in right/left lower limb.

Right Left
LIMB LENGTH
ASIS to Medial Malleolus : cm cm
ASIS to Knee Joint Line : cm cm
Impression: There is ……. limb length discrepancy

MUSCLE GIRTH ( girth in centimeters )

Thigh circumference (15cm above patella): cm cm
Calf circumference at maximal point : cm cm
Impression: There is muscle wasting of …cm in ….. thigh and …cm in ….. calf

RANGE OF MOVEMENTS ( in degrees) Right Left

Hip

Flexion 0- ° 0- °

Abduction 0- ° 0- °
Adduction 0- ° 0- °

Internal Rotation 0- ° 0- °

External Rotation 0- ° 0- °
Impression: Range of motion in both hips are equal. Range of
motion in right/left hip is impaired.

Knee Right Left

Effusions nil? nil?
Ligaments of knee NAD? NAD?
ACL
PCL
MCL
LCL

Flexion / Extension (in degrees) 0- ° 0- °

Impression: Range of motion in both knees are equal. Range of
motion in right/left knee is impaired.

[Noted posterior sag in right/left knee, with posterior drawer test positive.
There is clinical evidence suggestive of right/left posterior cruciate ligament
(PCL) injury.]
NOTE: PCL injury in right/left knee is not mentioned in the initial medical report from
Hospital ………., dated …….. Kindly confirm with the hospital.
Ankle (in degrees)

Plantar Flexion 0- ° 0- °

Dorsiflexion 0- ° 0- °

Inversion 0- ° 0- °

Eversion 0- ° 0- °
Impression: Range of motion in both ankles are equal. Range of
motion in right/left ankle is impaired.

Range of motion in ……….ankles……..

 Toes Range of MTPJ PIPJ/IPJ DIPJ
Motion
( in degree )
Great toe
2nd toe
3rd toe
4th toe
Little toe

NEURO VASCULAR ASSESSMENT NAD NAD

OTHER IMPORTANT FINDINGS (including Trendelenburg’s test ect )

RADIOLOGICAL FINDINGS
Latest x-ray done on ………….reveal fracture …………………..has united and
…………………..is in situ
OVERALL LOWER LIMB IMPRESSION
Fracture has
Gait
Shortening
Deformity
Muscle wasting
Range of motion
Scar / Other relevant finding
SPINE EXAMINATIONS:

SCAR : Nil
BACK DEFORMITY : Kyphotic thoracic spine
TENDERNESS : Nil

RANGE OF MOTION AT LOWER SPINE (in degrees)

Forward flexion 0-30°

Extension 0-10°

Right lateral flexion 0-10°

Left lateral flexion 0-10°

Right internal rotation 0-60°

Left internal rotation 0-60°

Impression: There is gross limitation of movement in lower spine.

SLR TEST
FABER TEST

NEUROLOGICAL EXAMINATION

OTHER IMPORTANT FINDINGS

SPINE RADIOLOGICAL FINDINGS

OVERALL SPINE IMPRESSION

Fracture has
Obvious spine deformity?
Spine Range of motion
Scar
Neurology
Sensation
Power
Reflexes
Muscle wasting UL / LL
UL function
LL function
Other relevant findings
CERVICAL SPINE EXAMINATIONS:

SCAR : Nil /
NECK DEFORMITY : Nil /
TENDERNESS : over fracture area?

RANGE OF MOTION AT CERVICAL SPINE (in degrees)

Forward flexion : 0-30°

Extension : 0-80°

Right lateral flexion : 0-30°

Left lateral flexion : 0-30°

Right lateral rotation : 0-80°

Left lateral rotation : 0-80°

Impression : Neck range of motion is limited in flexion.

NEUROLOGICAL EXAMINATION : NAD
OTHER IMPORTANT FINDINGS
CERVICAL SPINE RADIOLOGICAL FINDINGS:
OVERALL SPINE IMPRESSION
Fracture has
Neck Range of motion
Scar, tenderness, deformity
Neurology
Sensation
Power
Reflexes
Muscle wasting UL / LL
UL function
LL function
Other relevant findings
CONCLUSION / OPINION / POSSIBLE TREATMENT:
……………………………… was allegedly involved in motor vehicle accident on
……………………………...
It was reported he/she sustained the following injuries:

Squealae of injury:
Although he had return to his work, he still continues to suffer from the
consequences of the accident in the form of (Symptoms)
He is unable to
Job
ADL
Examination on…………………….shows the following:
Fracture has
Gait
Shortening
muscle wasting
Range of motion (The outcome of physio can vary from person to person).
scar
Other relevant findings

Opinion and possible treatment:

Thank you.

Yours faithfully,

…………………………………
Dr Suresh Kumar J Hariharan,
MBBS (India), MS (ORTHO) UKM,
Consultant Orthopaedic & Trauma Surgeon.