CHIEF COMPLAINT: Left thumb injury.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department this evening, accompanied by her father, for evaluation of hyperextension injury that she suffered to her left thumb yesterday while playing volleyball at practice. She has noted some increased pain with active range of motion of the thumb today, so she presents now for evaluation and treatment.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a nonsmoker and denies substance or alcohol abuse.
REVIEW OF SYSTEMS: The patient denies fever, chills, nausea, vomiting or diarrhea. She denies any bony deformity, ecchymosis or hematoma to the left thumb. The patient does note some pain with active range of motion of the same. Otherwise, she denies any erythema, edema or crepitus to the affected digit. The remainder of the review of systems, otherwise, is negative as it pertains to chief complaint.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 82, respirations 16, BP 144/78, and pulse oximetry 99% on room air.
GENERAL: The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old Hispanic female.
MUSCULOSKELETAL: Focused musculoskeletal examination reveals tenderness to the thenar eminence of the left thumb. There is no evidence of bony deformity, ecchymosis or hematoma. There is no erythema, edema or crepitus to the same. The patient exhibits full but painful range of motion of the digit, predominantly with flexion of the thumb. She, otherwise, exhibits strong distal radius pulse and brisk capillary refill in all digits of the left hand.
NEUROLOGIC: Reveals no gross motor or sensory deficits. The patient is alert, cooperative, and exhibits intact distal sensation in all digits of the left hand as well.
INTEGUMENTARY: Without diaphoresis, rashes, lesions. Skin is warm and dry to touch, normal tone and turgor.
DIAGNOSTIC DATA: X-rays obtained of the patient’s left thumb revealed no fracture, dislocation or other bony abnormality as reported by the radiologist.
EMERGENCY DEPARTMENT COURSE: The patient’s left thumb was placed in a thumb spica splint prior to discharge. Splint placement as well as distal neurovascular status was assessed after placement and found to be acceptable and within normal limits.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient and agreed with the final diagnosis of left thumb contusion with sprain and the treatment plan that follows.
PROCEDURE: None.
CONSULTATIONS: None.
IMPRESSION: Left thumb contusion with sprain.
PLAN:
1. Rest, ice, compress, and elevate for the next 48 hours, then soak in warm water.
2. Over-the-counter ibuprofen, up to 600 mg three times daily with food.
3. Follow up with orthopedist on call in two to three days for re-evaluation.
4. Return to the emergency department for any worsening symptoms or new concerns.
DISPOSITION: The patient was discharged to home in good condition.
