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CHIEF COMPLANTS:
Right hand pain.

 

HISTORY OF PRESENT ILLNESS:
The patient is a young man with no significant past medical history, works as a receiving manager for a home depot, was receiving some boxes of tile when suddenly three boxes of tile fell on his right hand sustaining injuries to his right index, right thumb and wrist. The patient was taken to XXXXX Hospital. According to him, x-rays were done and a questionable fracture was detected in the thumb, for which the patient was referred to a hand specialist and the patient was treated by him and was supposed to start occupational therapy but the patient did not as it is too far away but came to this office for evaluation and treatment.

 

PAST MEDICAL HISTORY:
The patient denies any history of hypertension, diabetes, or coronary artery disease.

 

PAST SURGICAL HISTORY:
Denies.

 

ALLERGIES:
He has no known allergies.

 

SURGERIES:
None.

 

PHYSICAL EXAMINATION:  The patient is alert, oriented and in mild distress.  Vital Signs: Stable.  HEENT: PERRLA, EOMI.  Neck Examination: Neck is supple. Flexion and extension did not produce any pain. There was no carotid bruit and no adenopathy.  Cardiac and Lungs Examination: Heart and lungs were clear.  Abdomen: Abdomen was soft. Umbilicus was central. All quadrants were moving with respiration. There was no guarding and bowel sounds were heard.  Extremity Examination: No edema, cyanosis, or clubbing.  Lumbosacral Spine Examination: Examination of the lumbosacral spine showed no tenderness of the lumbar spine on palpation with tender paravertebral muscles. Straight leg raising test was negative bilaterally. Flexion/extension and squatting were not reduced. Right hand examination showed index finger and right thumb to be in splint. Range of motion was completely decreased because of pain. There was good capillary refill but sensation was decreased.

 

IMPRESSION:
Trauma to the right index and left thumb.

 

PLAN:
The patient is to be evaluated by hand surgeon and will need occupational therapist to facilitate this as soon as possible. We will refer patient to Dr. XXXXX and possible get occupational therapy.

Orthopaedic Medical Transcription Report