CHIEF COMPLAINT: Left collar bone injury.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female. At approximately noon today, she fell in the wet grass and tried to catch herself using the left arm. Since then, she has had pain along the left clavicle area. She denies prior injury.
PAST MEDICAL HISTORY: Negative. She is otherwise healthy.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: None.
CURRENT MEDICATIONS: Amoxicillin, which she is taking for upper respiratory infection.
REVIEW OF SYSTEMS: See HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 114/70, temperature 97.4, pulse 108, respirations 18, and pulse ox 98%.
GENERAL: The patient is a (XX)-year-old female in no acute distress. She is alert, oriented, and cooperative throughout the examination.
HEENT: Within normal limits.
NECK: The patient has no pain to palpation on the cervical spine.
BACK: No trauma. The patient is nontender to palpation along the spine.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender.
EXTREMITIES: The patient has limited range of motion of her left upper extremity. She is nontender along the shoulder, elbow, wrist, hand. Her main complaint is tenderness to palpation along the mid aspect of the clavicle. Slight soft tissue swelling noted. No evidence of ecchymosis, no discrete step-offs noted, no breaks in the skin. Distally, her sensation is intact. Her capillary refill is less than 2 seconds. Distal pulses are intact.
RADIOLOGY: Left clavicle x-ray was obtained that showed a small, nondisplaced fracture of the clavicle along the mid aspect. X-ray results are reviewed. She was placed in a sling.
IMPRESSION: Acute nondisplaced left clavicle fracture.
PLAN:
1. Ice.
2. Sling daily until followup with orthopedics this week. Referral number was given.
3. Tylenol, ibuprofen p.r.n.
4. No sports or gym until followup.
5. Return if worse.
DISPOSITION: The patient was treated and released in stable condition.
