H&P #2

Identifying data:

  • Date & Time: 1/12/23 11:00 am
  • Full name: Mr. S. R.
  • Address: Queens, NY
  • Date of birth: March 13, 2005
  • Location: Centers Urgent Care, Middle Village
  • Religion: Unknown
  • Marital status: Single
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self
  • Mode of transport: Father via car

 

Chief Complaint: “Injured right hand” x 2 days

History of Present Illness:

17 y/o M with no significant past medical history c/o RIGHT hand pain x 2 days. Pt admits to trauma 2 days ago after punching a wall. Describe pain as sharp and 7/10 severity. States pain does not radiate anywhere, centered around lateral aspect of hand. Reports pain worsens with flexion. Pt is RIGHT hand dominant. Denies past injuries to this hand. Denies loss of sensation, numbness, tingling, fever.

OTC use with ibuprofen 400 mg, last dose 4 hours ago, reports some relief of pain.

 

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food or environmental allergies

Family History:

  • Mother: alive and well, no significant PMHx
  • Father: alive and well, no significant PMHx
  • Maternal grandparents: unknown
  • Paternal grandparents: unknown
  • Brother: alive and well

Social History:

  • Smoking: non-smoker
  • Substance use: denies alcohol or drug use
  • Caffeine: none
  • Occupational history: student
  • Home situation: lives at home with parents and brother
  • Exercise: daily gym class

 

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Ears: Denies deafness, ear pain, discharge, tinnitus, hearing aid use.
  • Nose: Denies discharge, obstruction, epistaxis.
  • Mouth/throat: Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies to edema/swelling of ankles or feet, hx of HTN, chest pain, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, abdominal pain, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Denies being sexually active. Denies history of STIs. Denies discharge.
  • Musculoskeletal: Admits to swelling of hand. Admits to hand trauma. Admits to hand pain. Denies arthritis, muscle pain.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical Exam:

Vitals:

  • BP: 130/82 (seated, right arm)
  • HR: 98 BPM (regular)
  • RR: 18/min (unlabored)
  • T: 98.9 F (oral)
  • O2: 99% (room air)

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: PERRLA. Visual fields full OU. EOM intact, no nystagmus. Sclera white, cornea clear, conjunctiva pink.

Ears: Symmetrical and appropriate in size. TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink and well hydrated.

Sinus: Non-tender to palpation.

Mouth/Pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, no tenderness, guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted. Capillary refill < 2 seconds.

Musculoskeletal:

  • Right hand: No acute deformity noted. Ecchymotic discoloration noted to dorsal aspect of palm. Diffuse swelling noted to lateral aspect of hand. Tender to palpation over distal 5th metacarpal and proximal 5th FROM intact with pain. Grip sensation diminished compared to contralateral side.

 

Initial Differential Diagnosis Based of Chief Complaint:

  1. Hand fracture
  2. Hand contusion
  3. Hand laceration
  4. Hand burn
  5. Compartment syndrome

 

Workup:

  • X-ray: RT hand
    • Radiologist read: oblique displaced fracture along base of 5th metacarpal

 

Adjusted Differential:

  1. Boxer’s fracture
  2. Hand contusion

 

Diagnosis: Fracture of 5th metacarpal, Right hand

 

Assessment: 17 y/o M with no significant PMHx presents with RIGHT hand pain x 2 days s/p trauma by punching a wall. Pain worsens with flexion. Pt is right hand dominant. On physical exam there is ecchymosis and diffuse swelling over lateral aspect of hand. Tender to palpation over 4th and 5th metacarpals. FROM with pain and diminished grip sensation. Xray reveals an oblique displaced fracture along the base of the 5th metacarpal.

 

Plan:

  • Apply ulnar gutter splint to immobilize 4th and 5th metacarpals
  • Pain: ibuprofen PRN
  • F/u with ortho within 48 hours
  • ER precautions: Patient advised to go to ER if numbness, tingling, pallor, loss of sensation.