Identifying Data:

Full Name: M.W

Address: Queens, NY

Age: 2 months old

Race/Nationality: African American 

Date and Time: 9/12/2021 9:40 AM 

Location: QHC Pediatric Emergency Department 

Source of Information: Mother

Source of Referral: Mother 

Reliability: Unable to obtain history from patient due to age 

Mode of Transport: Private vehicle 

Chief Complaint: right third toe swelling x several hours 

History of Present Illness: 

2-month-old female, NSVD 39 weeks 2 days no complications, with no past medical history, presenting with right third toe swelling that started several hours ago. Per the mother, she picked up the patient around 3AM to change her diaper and noticed the patient’s toe was swollen. Mother states the patient was not crying uncontrollably. Mother states she believes there is hair wrapped around the patient’s toe but does not know when the event initially occurred. She states the patient is up to date on all her immunizations. Mother denies that the patient had any known insect bites or change in laundry products. She states she did not give the patient any medication for pain. Mother denies that the patient has fever, decreased formula intake, vomiting, change in bowel habits, decrease in wetting diapers or any other symptoms at this time.

Past Medical History:

• Denies present or past illnesses.
• Denies any hospitalizations, transfusions, or injuries

Past Surgical History:

• Denies surgeries in the past.

Family History: 

• Mother: alive and well, gestational diabetes 
• Father: alive and well 
• Brother: alive and well 
• Sister: alive and well 

Medications:

•  Denies 

Allergies:

• No known drug, food, or seasonal allergies. 

Immunizations:

• Up to date

Social history:

• Patient lives at home with mother, father and two older siblings in a smoking household.
• Currently the mother is at home on maternity leave with the patient. 
• No recent travel

Nutrition:

• Patient receives formula and is feeding well. 

Sleep:

• Mother denies any sleeping difficulties in the patient 

Review of Systems: 

General: Denies fever, weight loss/gain or decreased appetite. 

Skin: Admits to swelling of right third toe. Denies rash, pruritus, or dry skin. 

Head: Denies head trauma. 

Eyes: Denies change in vision. 

Ears: Denies discharge or ear tugging.  

Nose/Sinuses: Denies nasal congestion or nasal discharge.

Mouth/throat: Denies bleeding gums or mouth ulcers. 

Neck: Denies neck stiffness, localized swelling/lumps or decreased range of motion. 

Respiratory: Denies cough, difficulty breathing, wheezing or sputum production. 

Cardiovascular: Denies leg edema, hypertension, syncope or known heart murmur.

GI: Denies change in formula intake, vomiting, hematemesis, diarrhea, constipation or change in bowel habits.

GU: Denies hematuria or change in amount of wet diapers.

MSK: Denies muscle or joint redness or stiffness. 

Neuro: Denies weakness. 

Physical Exam: 

VS: T 98.6 F, HR 146 bpm, RR 34 unlabored, O2 sat 100% on room air, Ht 55 cm, Wt 5.48 kg

Gen: Alert and responsive with strong cry. Well-developed and well-nourished. 

Skin: Warm and dry. No rashes or pigmentations. 

Head: Normocephalic, atraumatic. Fontanelles not sunken.  

Ears: Well-formed pinna bilaterally. 

Eyes: Pupils equal, round and reactive. Sclera non-icteric.

Neck: Trachea midline, supple. 

CV: Regular rate and rhythm. S1 and S2 with no murmurs or gallops.

Resp: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing

Abd: Soft, non-tender, no masses. No organomegaly. 

Neuro: Easily aroused, good symmetric tone. Symmetric Moro reflex. 

Ext: Right third toe with edema and toe hair tourniquet tightly embedded in skin. Decreased perfusion to the toe with no significant discoloration. All other digits with 2+ capillary refill with no signs of hair tourniquets. Patient has full range of motion of extremities and digits. 

Differentials: Hair tourniquet, trauma, allergic reaction, contact dermatitis, insect bite 

Assessment: 

2-month-old female, with no PMHx, who presents with right third toe swelling x several hours. Physical exam reveals a hair tourniquet on the toe with swelling and hair tightly embedded in the skin with no other abnormalities. 

Plan: 

Hair Tourniquet 

• Remove the hair tourniquet with suture kit 
• Several strands of hair removed from the patient’s toe
• Good perfusion to toe, with no blue discoloration or signs of ischemia. Minimal bleeding occurred. 
• Bacitracin applied to toe and wrapped with gauze and tape 
• Monitor patient for an hour in the emergency department

Addendum: 

• Patient monitored in the ED for an hour with mother – patient in no acute distress, sleeping.
• Good perfusion to right third toe, with mild decrease in swelling  
• Discussed wound care with the patient, including applying Bacitracin and wrapping the toe.
• Discussed with the mother that the patient should return to the ED if she has fever, decrease in feeding, decrease in wet diapers or warmth, edema, or erythema to the toe. 
• Prescribed Keflex 125 mg/5mL suspension – take 2.5 mL by mouth three times a day for five days 
• Discussed with mother to brush her hair frequently to remove loose hair and wash clothes separately. 
• Check feet and hands after each diaper change and after bathing. 
• Follow up with pediatrician in two days for reevaluation and wound care