CHIEF COMPLAINT: Left hand pain, right wrist injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presents to the ER with a history of accident that occurred earlier today at approximately 7 p.m. The patient claims he was roller skating and he slipped and fell. He claims he hurt his right wrist, which is now swollen. He also hurt his left hand just distal to the wrist, which has some swelling. He also hurt his lower back a little bit more to the side, unilaterally; however, no numbness, weakness, paresthesias of the lower extremities. The patient claims there was no head strike. There was loss of consciousness. He denies any headache. He denies any neck pain. He denies any chest pain. He denies any shortness of breath. He denies any nausea or vomiting. He denies any abdominal pain or any weakness to the extremities. Due to the above injuries, which are aggravated by touching or movement including some discomfort to the patient’s tailbone which is aggravated by sitting, he now presents for further evaluation and care.
PAST MEDICAL HISTORY:
1. History of atrial fibrillation, status post ablation.
2. History of basal cell CA.
ALLERGIES: The patient denies any allergies.
CURRENT MEDICATIONS: Coumadin, propafenone 250 mg t.i.d., Tylenol as needed.
SOCIAL HISTORY: Negative history of tobacco. Occasional alcohol use. Negative for history of recreational drug use.
REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies. HEENT: Denies any injury. He denies any headache, neck pain or difficulty swallowing. CARDIAC: Negative for chest pain or palpitations. RESPIRATORY: Negative shortness of breath, cough, sputum production. GASTROINTESTINAL: Negative history of nausea, vomiting, abdominal pain. GENITOURINARY: Negative history of hematuria, dysuria or incontinence of urine since the time of accident. MUSCULOSKELETAL AND NEUROLOGIC: As above, otherwise unremarkable. The patient claims he was able to ambulate since the time of the injury.
PHYSICAL EXAMINATION:
GENERAL: Revealed a Hispanic male who is alert and oriented x3.
VITAL SIGNS: Temperature 97.6, blood pressure 144/96, pulse 74, respirations 18 and O2 saturation 96%.
HEENT: Head is atraumatic. Eyes: Pupils are equal, round and reactive to light. Sclerae are nonicteric. EOMs intact. Oral mucosa is moist.
NECK: Supple. C-spine is nontender as well as thoracic spine. Nontender LS spine. Diffuse paraspinal musculature tenderness. Negative for CVA tenderness. Negative for bony tenderness. Sciatic notch is nontender. Pelvis without crepitance.
EXTREMITIES: Hips with good range of motion. Log roll is negative bilaterally. SLRs are positive for back pain only. The distal extremities are warm to touch and noncyanotic. DP/PT pulses are strong, intact and equal bilaterally. EHL extremities 5/5 as well as other muscle strength testing of the upper and lower extremities. Sensation is intact throughout the upper and lower extremities. Shoulder and elbows are unremarkable bilaterally. The wrist exam on the right does reveal tenderness in the area diffusely about the wrist. There is swelling in the same area, particularly in the carpal bones. The wrist range of motion is slightly diminished, although intact. Fingers have full range of motion without scissoring, no palpable tenderness. Distal neurovascular is again intact. Attention drawn to the left wrist, again there is some tenderness, particularly about the first metacarpal diffusely. Full flexion, extension, range of motion of the fingers and thumb. No scissoring and no abnormalities noted. Again, distal neurovascularly intact. There is questionable element of swelling. No ecchymosis and no obvious deformity. Wrist has good range of motion. It should be noted the snuff box is not tender bilaterally.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:
The patient was seen and evaluated. X-rays were done which included bilateral wrist and hands and LS spine. LS spine was read as negative, acute fracture of the wrist. The right was read as positive for fracture, dorsally, lunate. The left wrist was read as negative. The patient was informed of these findings. Rectal exam was done, which failed to reveal any loose pieces of coccyx; although, tenderness is noted throughout the sacrum and coccyx area. No further abnormalities were noted. Sensation was intact in the buttocks and area of the perianal and perineum to soft touch. The patient was informed that he would need a sugar tong splint of the involved fractured extremity and sling, elevate, ice to all areas. The patient was advised no lifting greater than 8 pounds, mandatory followup with his PCP within 1 week. The patient is also to call his PCP to establish himself with a hand surgeon for followup within the next week with regards to his wrist injuries, particularly the fracture. The patient indicated understanding and agreement with all of the above and furthermore he was instructed to return to the ER if he has worsening signs or symptoms, development of problems, weakness, incontinence of urine or stool. The patient was also advised if he chooses to take Vicodin as prescribed for pain, he should not take his usual Tylenol. He was given prescription for Vicodin one q.6 h. as needed for pain control with warning of drowsiness, do not drink, drive or work, he was given a total of 21.
DIAGNOSES:
1. Status post mechanical fall.
2. Left wrist hand contusion.
3. Right wrist fracture.
4. Lumbosacral contusion pain.
DISPOSITION: The patient was discharged home in stable condition.
