CHIEF COMPLAINT: Right thumb injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presents to the emergency department for a right thumb injury. The patient states that yesterday while working, the patient’s finger got caught in the gearbox of a tractor. At that time, the patient states his thumb got smashed. The patient states that he went to an outside facility yesterday and had x-rays done at that point.
The patient states that he was told he needed followup with a hand surgeon and was discharged with Keflex and Percocet for pain. This is a right-handed dominant male who denies any numbness of that extremity; however, he states he does have some tingling. The patient also denies any decreased range of motion. The patient states that his tetanus vaccination was out of date; however, it was updated at the outside facility today. The patient was sent here for a referral to Hand Surgery.
PAST MEDICAL HISTORY: The patient denies any significant history.
CURRENT MEDICATIONS: Keflex and Percocet as needed.
ALLERGIES: PENICILLIN CAUSES HIVES.
SOCIAL HISTORY: The patient denies use of tobacco, illicit or IV drugs and states he occasionally drinks alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/94, pulse 72, respirations 20, temperature 97.2, and O2 saturation 98% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old male who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative, communicates well, and is ambulatory here in the emergency department.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops noted.
EXTREMITIES: Focused examination on the patient’s right upper extremity shows 2+ radial and ulnar pulses with intact radial, median, and ulnar nerves. The patient has a soft tissue amputation of the right thumb, approximately 15 x 20 mm, extending from the dorsal aspect of the distal phalanx to the pulp of the right thumb. This has gone through the nail bed. The patient has no active bleeding at this time. The patient has full flexion and extension at the MP and IP joint of the right thumb. The patient, upon evaluation, has no viewable bone.
NEUROLOGIC: Cranial nerves II through XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. The patient is alert and oriented x3.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, an x-ray was ordered on the patient’s right thumb, which did show soft tissue amputation of the thumb with no osseous abnormality and negative for fracture or dislocation. The patient was then seen and evaluated by the residents on call for Plastics. Upon finishing his examination, did re-dress the patient’s wound with both bacitracin as well as Adaptic. The patient was given dressings for daily wound care until his followup with Hand.
DIAGNOSIS: Right thumb soft tissue amputation.
PLAN:
1. Continue antibiotics until completely finished.
2. Continue Percocet as prescribed, as needed, for pain.
3. Daily wound care as discussed with Plastics.
4. Follow up with Plastics, Hand.
5. Return for any worsening of symptoms or signs of infection such as increased redness, swelling, purulent drainage or other concerns.
DISPOSITION: The patient was discharged to home in stable condition.
