Chief Complaint & History of Present Illness :
Chief complaint: Right hand/wrist pain
History of present illness: The patient is a 29 year old female presenting with right hand/wrist pain that started last night after she accidentally hit her and gets basketball rim. Pain is worse at the lateral aspect along the little finger. Pain is worsened since that time, minimally improved with an Ace wrap. Denies any numbness, tingling or weakness
Medical Decision Making (MDM) :
29-year-old female with right wrist pain. 2+ pulses, capillary refill less than 3 seconds, motor strength 5/5 and sensation grossly intact at the right upper extremity. For pain, I recommended alternating ibuprofen and Tylenol. Xray of the right hand showed an angulated fracture of the fifth metacarpal. Patient was placed in a fiberglass ulnar gutter splint under my supervision with in tact distal neurovascular exam after placement. Referred to Hand surgery. Counseled and educated patient on treatment plan and risks and benefits of treatment. Patient understands that we are not able to diagnose all conditions in the emergency department, and that although at this time there are no worrisome symptoms and patient appears to be stable, patient will need to return at once if any recurrent, worsening, or new symptoms. Provided literature in after visit summary. Assessed for patient understanding and answered all of the patient’s questions completely.
t ED Diagnosis (Current Problem List)
Problem Associated ICD-10-CM Code Status Onset
Closed fracture of fifth metacarpal Active 2018
562.306A- UNSPECIFIED FRACTURE OF FIFTH
METACARPAL BONE, RIGHT HAND, INITIAL
ENCOUNTER FOR CLOSED FRACTURE
Past Medical History :
PMH: No diabetes or hypertension
Surgeries / Procedures: Appendectomy, cholecystectomy
Allergies
No Known Allergies
Home Medications
None Reported : HOME MEDICATION Last Documented By: RICHARD D BURCH, RN on 07/23/2018 16:15
Social History
Occasional alcohol. No drug use. No tobacco use.
Review Of Systems
ROS: Constitutional: No fevers, chills,
Head: No headaches, head injury.
Neurologic: No fall. No numbness, tingling, weakness, syncope.
Musculoskeletal: No back pain. No neck pain. Positive right hand joint pain.
Peripheral vascular: No persistent bleeding. No cyanosis. No anticoagulation therapy.
ROS: Skin: No rash. No laceration. No ecchymosis.
Vital Signs
Most Recent Set of Vitals:
BP: 131/92 07/23/2018 16:13
Pulse: 86 07/23/2018 16:13
Temp: 36.7 C 07/23/2018 16:13
Resp: 16 07/23/2018 16:13
02 Sat: 97%(Room Air) 07/23/2018 16:13
Calculated BMI: 37.6 07/23/2018 16:13
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 97 % Interpretation: Normal Date/Time:
Physical Exam
GENERAL
Vitals: Reviewed by me.
Constitutional: Well developed, well nourished. No acute distress.
Head: Atraumatic, Normocephalic.
Musculoskeletal: No obvious deformity or bony step-offs. Full range of motion.
Hand/wrist/digits: No tenderness to palpation of wrist, MCP, PIP, DIP and CMC joints bilaterally, with the exception of the right ulnar styloid process and right 5th meta carpal and proximal phalanx. No flexor or extensor sheath tenderness to palpation. No scaphoid tenderness.
Neurologic exam: Awake, alert, and oriented to time, place, and person. CNII-XII grossly intact. Motor strength is 5/5.
No sensory deficits with light touch. Patellar tendon reflexes 2+ bilaterally. No deficits with finger-nose-finger, or rapid
alternating movements. Gait is not antalgic. Bears weight without assistance.
Peripheral Vascular: Radial pulses 2+ and equal. Capillary refill less than 3 seconds. No upper or lower extremity edema bilaterally.
Skin: Warm, dry. No erythema, edema, or lacerations.
Viewed and interpreted by radiologist
FINDINGS:
Bony structures of the right hand demonstrate a mildly angulated fracture of
the 5th metacarpal. The remaining bony structures are intact. Articulations
appear normal.
IMPRESSION:
1. Minimally angulated fracture of the 5th metacarpal.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Closed fracture of fifth metacarpal 562.306A- UNSPECIFIED FRACTURE OF FIFTH Active 2018
METACARPAL BONE, RIGHT HAND, INITIAL ENCOUNTER
FOR CLOSED FRACTURE
CPT code :
99283-25
73130-RT
29125-RT Application short arm splint forearm-hand static