CHIEF COMPLAINT: Burn.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presents 30 minutes post hot water burn to both hands. She presents due to severe pain. She denies any other injuries. No numbness, tingling or weakness. The patient states that she has decreased ability to move her hands due to pain. No sensory or motor loss. No other injuries.
PAST MEDICAL HISTORY: The patient denies hypertension and diabetes.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient does not drink and does smoke.
ALLERGIES: NKDA.
MEDICATIONS: None.
IMMUNIZATION STATUS: Less than 5 years.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a (XX)-year-old female in moderate distress secondary to pain.
VITAL SIGNS: Reviewed and on the chart. The patient is hypertensive due to pain. The patient does not have a history of hypertension.
SKIN: The patient has areas of erythema to both dorsal surfaces of the hands. There are a few scattered intact blisters to the dorsal surface of the right hand. These measure between 1 and 2 cm. The burns are not circumferential. There is no fluffing of the skin. There are no burns above the wrists. The palms are clear. She is able to extend her fingers freely and move them. The patient has intact sensation with good distal pulses, good capillary refill. Swelling is mild.
HEENT: Within normal limits.
NECK: Supple. Full range of motion.
LUNGS: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Obese, large pannus, soft and nontender.
EXTREMITIES: As described above.
EMERGENCY DEPARTMENT COURSE: The patient is given Dilaudid 1 mg IM along with 4 mg of Zofran IM. Cool compresses were applied to the skin. After a period of time, the patient’s wounds were cleansed and dressed with Silvadene. The patient was reexamined before the dressings were applied once again reconfirming that the wounds are not circumferential.
DIAGNOSIS: First degree and second degree burns to both hands.
PLAN:
1. The patient is given a prescription for Percocet 5 mg, #20.
2. Wound dressings are applied, and she is told to keep these on and intact and return to the ER in 24 hours for recheck.
3. The patient is to elevate her hands, keep cool compresses and to return sooner to the emergency room if there are any problems.
DISPOSITION: Discharged.
