RT3-Ambulatory care H&P3

Jinjin Lin

 

Identification:

Patient’s name: Ms. C

DOB: 28 years old

Gender: male

Race: Caucasian

Location: Centers urgent care, Brooklyn, NY

Date and Time: 3/30/2019, 11pm

Informant: self, reliable

CC: “my hand hurts a lot” X 2 hours

HPI: A 28 years old Caucasian male with no significant past medical history complaints of pain over right 3^rd, 4^th, and 5^th metacarpals for 2 hours after a fight. Reports gets involved in a flight and punches a guy, also notes swelling, warmth, and bruising on the right hand. Reports limitation to move right metacarpals and phalanges due to pain. Took OTC Motrin, 200mg, 1 hour ago. Denies wrist pain, fight bite, decreased sensation, loss of sensation, numbness, or tingling.

PMH:

Patient denies any past medical history.

Past Surgical History:

Patient denies any past surgical history.

Medications:

OTC Motrin 200mg, PO, PRN

Allergies:

Patient denies any drug, foods, or environment allergies.

Family History:

Father- 54, alive and well

Mother- 51, alive and well

Social History:

Mr. C lives with his wife in Brooklyn, NY. He works as lawyer and owns a law office. Usually sleeps for 7 hours a day with good sleep quality. Walks his dog for 45 min every day, tries to balance his diet. Denies recent travel, nicotine use, alcohol consumptions, past or present illicit drug use.

ROS:

General: Patient denies fever, chills, loss of appetite, recent weight loss or weight gain, generalized weakness, or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat

Neck: Patient denies localized swelling or lumps, stiffness

Breast: Patient denies lumps, nipple discharge, pain.

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies abdominal pain, diarrhea, cannot tolerant solid food, vomiting, dysphagia, jaundice, hemorrhoids, constipation, rectal bleeding, blood in stool

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, incontinence, hesitancy, dribbling or last prostate exam

Sexual history: Patient is sexually active with his wife only and use contraception, patient denies STD

Nervous System: Patient denies seizures, headache, loss of consciousness, numbness, paresthesia, loss of strength, change in mental status, memory, or weakness

Musculoskeletal System: Patient reports swelling and bruising of right hand, muscle and joint pain, denies deformity or arthritis

Peripheral System: patient denies intermittent claudication, peripheral edema

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, anxiety, seen a mental health professional, or use medications

Physical Examination:

General: 28 years old male is alert and cooperative, well developed, well nourished, neatly-groomed, in no acute distress

Vital Signs:

BP (seated): 138/86

HR: 88 BMP, regular

RR: 18, not labored

Temp: 93.6 F oral

O2 sat: 98% room air

Height: 5ft 2in weight: 145lb BMI: 28.32, overweight

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

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

Eyes: Symmetrical OU; sclera white; conjunctiva & cornea clear. PERRLA, EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, cone of light intact

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, moist, no cyanosis or lesions

Mucosa: Pink, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars

Teeth: Not wearing dentures

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline. Supple nontender to palpation. 2+ carotid pulses, no thrills, bruits bilaterally. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse are 2+ bilaterally without bruits

Abdomen: Flat, symmetrical. Bowel sounds in all 4 quadrants. No bruits. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Rectal: No examined

Male genitalia and hernia: No examined

Anus, rectum, and prostate: No examined

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits, clubbing, cyanosis or edema noted

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact

Cranial nerve:

I – not exanimated

II- Visual fields by confrontation full

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active and passive ROM. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). Gait normal with no ataxia

Sensory: Intact to light touch, point localization, stereognosis and graphesthesia testing bilaterally

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System: + Right hand: swelling and mild bruising noted, tenderness to palpation along 4^th and 5^th metacarpals, capillary refills < 2 seconds, 3+ radial pulse, no wrist pain or tenderness, 5/5 grip strength, no neurovascular compromised noted

X-ray of right hand:  5^th metacarpal fracture noted

NOTE: I did not put any differentials for this one, it was clear that patient had boxer’s fracture.

Assessment: A 28 years old male with no significant past medical history complaints of pain over right 3^rd, 4^th, and 5^th metacarpals for 2 hours after a fight. Reports swelling, warmth, and bruising and limitation of metacarpals and phalanges movements due to pain. Physical examination findings with swelling, bruising, tenderness along 4th and 5th metacarpals, capillary refills < 2 seconds, 3+ radial pulse, no neurovascular compromised noted. Xray of right hand with 5^th metacarpal fracture.

Plan:

• Boxer’s fracture:
• Ulnar gutter splint applied
• Discharge instructions reviewed and discussed with patient
• Continue Motrin as needed
• Keep splint in place until follow up with ortho
• Avoid strenuous activities at this time
• Proceed to ER if any worsen or concerning symptoms develop, including increase in pain, swelling, numbness, tingling, fever, chill