CHIEF COMPLAINT: Painful index finger, left hand.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old man presents complaining of a painful index finger, left hand, progressive for 1 week. Cannot relate any specific injury or laceration sustained. The patient has had progressive pain and swelling. This is his second visit here for the same complaint. He has been on different antibiotics. Currently, taking Vibramycin and Bactrim, but worsening. Now, having the pain extending all the way down to the hand.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: No use of alcohol. Positive for tobacco, one pack per day.
FAMILY HISTORY: Negative.
ALLERGIES: None.
CURRENT MEDICATIONS: Vibramycin, Bactrim, Lortab p.r.n.
REVIEW OF SYSTEMS:
GENERAL: Has no fever or chills.
HEENT: No change in vision. No earache, sore throat or sinus congestion.
NECK: No pain or stiffness.
CARDIOVASCULAR: No chest pain or pressure. No palpitations.
PULMONARY: No shortness of breath, cough or wheeze.
GASTROINTESTINAL: No abdominal pain, nausea, vomiting or diarrhea, melena, or bright red blood per rectum.
GENITOURINARY: No urinary frequency, urgency, hesitancy or dysuria.
MUSCULOSKELETAL: Progressive pain with stiffness in the second digit of the left hand.
DERMATOLOGIC: No rash, no itching, no lesions.
ENDOCRINE: No polyuria, polydipsia, no heat or cold intolerance. No recent change in weight.
HEMATOLOGICAL: No anemia or easy bruising or bleeding.
NEUROLOGIC: No headache, seizures, numbness, tingling or weakness.
PSYCHIATRIC: No depression, no loss of interest in normal activity or change in sleep pattern.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6, blood pressure 166/92, heart rate 82, respirations 20, and pulse oximetry 98%.
GENERAL APPEARANCE: He is awake and alert and appears well developed.
HEENT: Head is atraumatic. Nasopharynx, tympanic membranes, oropharynx clear. Mucous membranes moist. Oropharynx without lesions or sign of trauma. Ophthalmological: On external examination, conjunctivae and sclerae are clear. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Funduscopic examination benign with normal disc margins.
NECK: Supple without jugular vein distension, thyromegaly, adenopathy, or meningismus.
LYMPHATICS: No localized or regional lymphadenopathy or subcutaneous masses.
CHEST: Chest wall is unremarkable. Breath sounds are clear. No wheezes, rales, or rhonchi. Good inspiratory and expiratory movement. No intercostal retractions.
HEART: Regular rate and rhythm without murmur, gallop, or rub.
ABDOMEN: Bowel sounds are active. Abdomen is soft, nondistended, nontender without masses, hepatosplenomegaly, costovertebral angle tenderness or palpable abdominal aortic aneurysm.
MUSCULOSKELETAL: Full and complete range of motion. No deformity or sign of trauma.
EXTREMITIES: Inspection of the left hand reveals the second digit to be quite swollen when compared to the right side. It is swollen all the way to the MCP joint, but most notably the distal phalanx. The digit is in almost complete extension. The patient cannot flex it, the DIP joint, whatsoever. He has very limited flexion at the PIP joint. There is no open wound, but he does have purplish discoloration to one area, of indurated tissue, on the flexor surface of the distal phalanx and measures 1 x 1 cm. The pain extends to the hand, but there is no erythema or any appreciable swelling to the hand itself.
NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves are intact. Deep tendon reflexes are 2+ and symmetric. Motor is 5/5 bilaterally. Sensation is intact bilaterally. Cerebellar function is normal. Gait is not ataxic. Babinski downgoing bilaterally, and there are no focal deficits appreciated.
PSYCHIATRIC: Normal affect. Eye contact is good. Speech is normal rate and content. Responses are appropriate.
SKIN: Brisk capillary refill. Normal color without rash or lesions.
IMPRESSION: Tenosynovitis, second digit, left hand.
PLAN: Discussed with Dr. John Doe. He requested the patient be kept n.p.o. He will see the patient in the ER.
DISPOSITION: Admitted.
