Identifying Data:

Full Name: M.C

Address: Queens, NY

Age: 25

Date and Time: 6/14/2021 2:30 PM 

Location: StatCare Astoria

Source of Information: Self

Source of Referral: Self

Reliability: Reliable patient 

Mode of Transport: Private vehicle 

Chief Complaint: right wrist pain x 1 day 

History of Present Illness: 

25 y/o M, with no PMHx, who presents to urgent care complaining of right wrist pain x 1 day. Patient states he was playing in a soccer match yesterday and felt right wrist pain after the match, but does not recall a specific injury or fall that caused the pain. However, the patient does admit to falling multiple times during the game. He states he started to apply ice last night and took a Tylenol, with minimal relief. He reports pain that is exacerbated by movement and states his pain is currently a 4/10. He states he is right hand dominant. He denies a history of fractures, dislocations or other trauma to his right hand or wrist. He denies fever, chills, numbness, tingling or bruising to his right wrist.   

Past Medical History: Denies 

Past Surgical History: Denies 

Family History: Non-contributory 

Medications: Denies 

Allergies: No known drug, food or seasonal allergies.  

Social history: Patient admits to occasional alcohol use. He denies tobacco or illicit drug use. 

Review of Systems: 

General: Denies fever, chills, night sweats, fatigue, weakness, weight loss/gain or decreased appetite. 

Skin : Denies rash, pruritus or dry skin. 

Head: Denies headache, dizziness or head trauma. 

Eyes: Denies blurry vision, double vision or loss of vision. 

Ears: Denies hearing loss, discharge, tinnitus, ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers. 

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

Respiratory: Denies cough, shortness of breath, wheezing, sputum production. 

Cardiovascular: Denies chest pain, leg edema, hypertension, syncope or palpitations. 

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea or constipation. 

GU: Denies  dysuria, hesitancy, flank pain, frequency, hematuria or urgency. 

MSK: Admits to right wrist/hand pain. Denies any other muscle or joint pain, redness or stiffness. 

Neuro: Denies weakness, dizziness, lightheadedness, headaches, numbness or tingling. 

Physical Exam: 

VS: T 98.5 F, BP 117/62, HR 69 bpm, RR 16, O2 sat 100%, Ht5’8”, Wt 186 lb, BMI 28.28

Gen: Alert and oriented, in no acute distress. 

Skin: Warm and dry. No rashes or suspicious lesions. 

Head: Normocephalic, atraumatic 

Eyes: PERRL. Sclera non-icteric. EOMI. 

Neck: Trachea midline, supple. 

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

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

MSK: Right anatomical snuffbox tenderness. No tenderness to right forearm, metacarpals, phalanges, elbow, humerus or shoulder. Full range of motion of the right wrist with mild pain mostly with flexion. No ecchymosis, erythema, edema or obvious deformity of bilateral upper extremities. Full range of motion right phalanges, elbow and shoulder. No tenderness to the left upper extremity and full range of motion.  

Neuro: 5/5 strength to left upper extremity. ⅘ strength to right wrist secondary to pain, 5/5 strength to rest of right upper extremity.  Sensation intact bilaterally to gross touch. 

Assessment: 

22 y/o M, with no PMHx, presents with right wrist pain x 1 day after injuring the area during a soccer match yesterday. Physical exam reveals right anatomical snuffbox tenderness and painful full range of motion of the right wrist with no other abnormalities. 

Differentials: Scaphoid fracture, muscle strain, other fractures… gamekeeper’s thumb, trapezium fracture 

Plan: 

• Go to Lenox Hill Radiology for x-ray of the right wrist today. Will call with results. 
• Thumb spica splint applied to right wrist for possible scaphoid fracture 
• Prescribed 500 mg Naproxen every twelve hours as needed for pain control. Discussed side effects of prescribed medications 
• Rest and avoid strenuous activity. Do not remove the thumb spica splint until discussion of x-ray results. 
• Referral to orthopedic surgery placed. Call for an appointment as soon as possible. 
• Patient agreed with the plan and all questions were answered.