Identifying Data:

Patient Name: John Doe

Date of Admission: 6/15/15
Age: 25
DOB: 4/6/1990
Gender: Male
Race: Caucasian
Medical Record #: 286384
Source: Self (seems reliable)

Chief Complaint: “My wrist hurts.”

History of Present Illness: Mr. Doe is a 25 year old Caucasian male who comes to clinic complaining of
pain in his left wrist. The patient states that the pain started three days ago when he fell on his hand while
playing soccer with some friends. He states that it is a dull, throbbing pain, but when he moves his hand it
is a sharp, severe pain. He rates the pain 7/10 and states it is constant. The patient also admits to erythema
and edema at the base of his left thumb. He states movement makes it worse. He tried taking ibuprofen for
the pain, which is somewhat alleviating.

Past Medical History:

Illnesses: Chicken pox as a child, gets a cold about once per year.

Surgeries: Wisdom teeth removal 6/10/2010

Medications: Ibuprofen for the pain

Allergies: None

Vaccinations: UTD on all childhood vaccinations, last flu vaccine 10/15/2014

Family History:
Father – HTN
Mother – unremarkable

Social History:
Patient is in graduate school and lives with one male roommate. Patient denies use of tobacco, but he
frequently drinks a bottle of beer with dinner and several on weekends. He has a girlfriend and is sexually
active.

Exercise and Diet: Patient participates in recreational sports a couple times a week, but does not exercise
otherwise. He eats fast food frequently.

Safety Measures: Patient regularly uses seat belt. Patient sometimes uses condoms.

Review of Systems:
General: Patient has noticed some weight gain since starting grad school, about 15 lbs.

Skin: See HPI

Identifying Data:
Patient Name: John Doe
Date of Admission: 6/15/15
Age: 25
DOB: 4/6/1990
Gender: Male
Race: Caucasian
Medical Record #: 286384
Source: Self (seems reliable)

HEENT: Patient denies history of head injury, problems in vision or hearing, or vertigo. Patients admits to
getting a cold once a year, including runny nose and sore throat, but none today.

Cardiovascular: Denies chest pain or tightness, palpitations, fainting or dizziness.

Respiratory: Denies cough, shortness of breath, wheezing, or painful breathing.

Gastrointestinal: Denies nausea, decreased appetite, diarrhea, constipation, difficulty swallowing, or

heartburn.

Genitourinary: Denies increased urinary frequency, urgency, or incontinence; denies pain on urination or
blood in urine.

Lymph nodes: Denies enlargement or pain.

Musculoskeletal: See HPI. Denies pain, stiffness, and swelling elsewhere.

Neurologic: Denies dizziness, fainting, seizures, weakness, numbness, tingling, or tremors.

Hematologic: Denies ease of bruising or bleeding.

Psychiatric: Denies general depression or anxiety.

Endocrine: No known thyroid trouble or temperature intolerance. Sweating average. Denies symptoms or
history of diabetes.

Physical Exam:
Vital Signs: BP 128/86; HR 64; T 98.8* F; RR 17; Wt 185 lbs; Ht 70”; SpO2 98% on room air

General Survey: Caucasian male who appears stated age; awake, alert, and oriented (A&O) x 3. In no
acute distress (NAD).

Skin: Erythema and edema localized to left radial side of wrist at the base of the thumb. Normal turgor
and texture, no rashes or lesions.

Head: Hair of average texture. Scalp without lesions, normocephalic/atraumatic (NCAT).

Eyes: Pupils equal, round, and reactive to light (PERRL), conjunctiva pink bilaterally, no scleral icterus,
extra-ocular motions (EOM) intact.
Identifying Data:
Patient Name: John Doe
Date of Admission: 6/15/15
Age: 25
DOB: 4/6/1990
Gender: Male
Race: Caucasian
Medical Record #: 286384
Source: Self (seems reliable)

Ears: Tympanic membranes are intact bilaterally without erythema or effusion.

Nose: No discharge or erythema. Mucosa pink, septum midline. No sinus tenderness.

Throat: No erythema, uvula midline, no tonsillar exudates observed.

Neck: Supple without jugular venous distention (JVD), no lymphadenopathy (LAN) palpated, trachea is
midline.

Cardiovascular: Regular rate and rhythm, S1/S2 present, no rubs, murmurs, or gallops (r/m/g). Capillary
refill <2 seconds; 2+ pulses in all 4 extremities, no clubbing or cyanosis. Localized swelling to radial side
of left wrist, no other extremity swelling or tenderness.

Respiratory: Clear to auscultation bilaterally (CTA-B) without any respiratory distress.

Abdominal: Soft, nontender, non distended; normative bowel sounds present in all four quadrants; no
hepatosplenomegaly; no masses; no guarding or rigidity.

Musculoskeletal: Left snuffbox tenderness upon palpation and movement, slight reduction in ROM of left
wrist and thumb, edema and erythema at base of left thumb. Full range of motion (FROM) in elbows,
shoulders, spine, hips, knees, ankles, and right wrist and hand. Extremities warm with symmetric muscle
tone.

Neurologic: Awake, A&O x 3. All cranial nerves intact.

Psychiatric: Affect and judgment are appropriate.

Labs: None currently.

Imaging: X-ray of left wrist shows scaphoid fracture.

Assessment:
1. Left scaphoid fracture
Differentials:
2. Distal radial fracture
3. Hand fracture
4. Scapholunate dissociation
Identifying Data:
Patient Name: John Doe
Date of Admission: 6/15/15
Age: 25
DOB: 4/6/1990
Gender: Male
Race: Caucasian
Medical Record #: 286384
Source: Self (seems reliable)

Plan:
1. Place left arm and hand in a cast.
2. Follow up frequently for x-rays, with first follow up in one week.
3. Avoid heavy lifting, pushing, pulling, carrying, or throwing with left arm. No contact sports. No
climbing. Avoid activities with risk of falling.
4. AROM and PROM exercises to digit except thumb, AROM and AAROM exercises to shoulder,
isometric exercises to biceps, triceps, and deltoid.
5. Continue use of NSAIDs as needed.
6. Discuss diet and regular exercise with patient.