DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Right thumb pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-hand dominant male who was playing volleyball earlier today when he fell injuring his right thumb. Since then, he has had pain. He is right-hand dominant. He denies numbness or tingling. He has pain, mainly at the base, in the distal joint of the thumb. No numbness or tingling. He has not taken anything for his symptoms. No previous history of trauma to this area.
PAST MEDICAL HISTORY: Asthma and heart murmur.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: Negative for tobacco, alcohol and drug use.
REVIEW OF SYSTEMS: A (XX)-year-old presenting with right thumb pain. See HPI for review of systems. All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 142/94, pulse 68, respirations 18, pulse ox 99% on room air, and temperature 98.4.
GENERAL: Otherwise healthy, well-developed, well-nourished (XX)-year-old male who is alert and oriented x3, nontoxic, in no apparent distress.
EXTREMITIES: On examination of the right thumb, the patient has some swelling and tenderness at the base as well as of the distal joint. He has no gross deformities. He does have some slight ecchymosis. He has two-point intact, good cap refill. He has no other tenderness to his hand or wrist. He has a good radial pulse. He is neurovascularly intact with normal function of median, radial, and ulnar nerve, and his joint does appear to be stable.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated by Dr. John Doe who agrees with the assessment and plan. The patient had an x-ray of the right thumb that showed a questionable fracture at the distal joint. Growth plates had not closed. The patient was put in a thumb spica splint and was given ibuprofen and one Tylenol No. 3 here in the emergency department for his pain.
MEDICAL DECISION MAKING: A (XX)-year-old presenting with thumb pain. At this point, there is a questionable fracture near the distal joint of the right thumb involving the growth plate that is not closed. He has been splinted and he has seen Dr. Jane Doe and will follow with her for further followup and management of this.
ASSESSMENT: Right thumb pain, rule out fracture.
PLAN:
1. Discharge the patient home.
2. Over-the-counter ibuprofen 400 mg three times a day with food.
3. He is given a prescription for Tylenol No. 3, dispensed #15, no refill, to take for severe pain.
4. Leave the splint on until followup.
5. He is to follow up with Dr. Jane Doe.
6. Return for further concerns.
