Daniel DeMarco Focused H&P#6 Ambulatory Care

Chief Complaint: Pain in Right Wrist x 4d

 

History of Present Illness:

MP is a 25yo Male presenting to office with complaint of Pain in Right Wrist on the ulnar side x4d. Patient states he was playing Softball on Sunday and after swinging the Softball bat, he began experiencing the pain. The pain comes and goes and is described as stabbing. It is aggravated by certain motions and worst with lateral movement of the wrist. Pain radiates up the ulnar aspect of the arm to the mid forearm. This is the first time the patient has experienced this and he has not tried anything for it. Denies previous injury to Right Wrist, direct trauma, sensory disturbances, motor impairment, cyanosis.

 

Allergies: NKDA

Medications: Denies

PMH: Left Shoulder Dislocation with Labral Tear 2014

PSH: Left Shoulder Surgery 2014

Social History: Admits social EtOH use. Denies tobacco use, marijuana use, other illicit drug use.

Family History: Denies

 

Review of Systems:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, congestion, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Admits Right Wrist Pain. Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Denies HI/SI, feelings of helplessness, hopelessness

 

Physical Exam:

Vital Signs:

BP: 116/76

Pulse: 94bpm

RR: 14 breaths/min

Temp: 36.8C

SpO2: 99%RA

Ht: 65.0 inches

Wt: 61kg

 

General Survey: Alert, NAD. Appears stated age.

Skin: No petechiae, masses, lesions. No jaundice, cyanosis, mottling. No rashes.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Musculoskeletal/Extremities: Right wrist with mild swelling. TTP over 2nd, 3rd, 4th palmar and dorsal aspect of metacarpals worse near CMC joint. TTP over ulnar styloid. Full active and passive range of motion with pain. Sensation intact. Radial pulse 2+ bilaterally.

 

Assessment/Plan:

MP is a 25yo Male with Right Intermittent Wrist Pain x 4d that is worse with certain movements and tenderness to palpation concerning for sprain versus fracture.

 

#Right Wrist Sprain versus Fracture

– XR Hand AP/LAT, XR Wrist AP/LAT, R/O: Fracture; Script given

– Right Wrist Brace applied

– Start Naproxen 500mg bid x 10d

– Ice x48h, then alternate heat and ice

– If severe pain, color changes of hand, sensory disturbances, go straight to ER

 

Follow-Up: prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student