Medical Transcription Services Company

EMERGENCY ROOM NOTE:
HPI:  13 year–old male riding his bike when he fell landing on his left thumb. He also scraped his right leg. He was not wearing a helmet. However he denies hitting his head. He has no neck or back pain. Denies chest or abdominal pain. Complaining mostly of left thumb discomfort.

PE:   He has a temp of 98.4, pulse 80, respiratory rate 18, BP 120/70. Neck is supple and nontender: Chest OK. Abdomen soft and nontender. Left elbow has full ROM without discomfort. Left forearm is nontender. There is no deformity. Left wrist is nontender with full ROM. Left hand tender over the first metacarpal. Left thumb is tender proximally. There is a small abrasion over the IP joint of the left thumb. X-rays show an oblique fracture of the first metacarpus which is nondisplaced.

IMPRESSION:  Closed fracture first left metacarpus and abrasions.

PLAN:   Placed in thumb spica splint. To elevate the extremity and apply ice. Given Tylenol for pain. To followup in 4 days.

Quick Inquiry
Name
Phone
Email
Description
Type the code shown below

Bookmark-www.brainstormworld.com