History and Physical – Rotation 6

Identifying Data

July 14th, 2022 – 10:45AM
GG, 36F, African American, Queens, NY
Informant: Patient, reliable
Referral Source: Self

Chief Complaint: “I have had right hand/wrist pain x4 week”

History of Present Illness:

36-year-old female with a past medical history of sickle cell trait presents to CitiMed JFK for evaluation for injury on duty of her right wrist and hand sustained 6/10/22. The patient works for Jet Blue as a baggage handler, and as she was grabbing luggage from the belt loader with her left hand, she accidentally hit her right hand as she threw the luggage into the plane. The patient states she was in immediate pain and but completed loading for the current flight. The patient states she reported the injury to her supervisor and was referred to this facility. Without completing her shift, she drove herself to this clinic for further evaluation and treatment. She denies any LOC, head trauma or any open wounds.

Today her right hand and wrist pain is rated 6/10, constant, throbbing, and worse with movement and gripping. She admits to pain radiating from the wrist to the interphalangeal joint of the thumb. Also admits to numbness and tingling at the thenar eminence as well as the lateral aspect of her right thumb. She reports using a splint with mild relief and takes one 500mg Tylenol Extra Strength twice daily with relief. She was evaluated by the facility’s affiliated hand surgeon on 6/24/22, who gave her a splint to be worn at all times and placed her on a prednisone taper, which she had completed. She was seen again on 7/6/22 and was given a steroid injection but reported increased pain and swelling. She is currently utilizing physical therapy 3 times per week. She currently denies headaches, vision changes, neck pain, chest pain, n/v/d, fever, and abdominal pain.

Past Medical History:

  • Sickle cell trait

Past Surgical History:

  • Denies

Medications:

  • Tylenol Extra Strength 500mg, PO PRN

Allergies:

  • Strawberries: swollen tongue
  • NKDA

Family History:

  • Father: Alive, unknown medical history
  • Mother: Alive, unknown medical history
  • Sister: Alive, unknown medical history

Social History:

  • Diet: Does not follow any specific dietary regimen
  • Home: Lives at home with her boyfriend.
  • Smoking: Denies current or past use of cigarettes, e-cigarettes, or other tobacco products
  • Alcohol: Admits to socially drinking alcohol once per week.
  • Drugs: Denies use of any illicit drugs.
  • Exercise: Admits to going to workout classes three times per week prior to injury
  • Sleep: Sleeps 7-8 hours per night, using 2 pillows.
  • Travel: Denies any recent travel

Review of Systems:

General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Positive corrected vision. Denies photophobia, double vision, blurry vision, excess tearing or dryness, or pruritis. Last eye exam in April 2022.

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, allergies, or epistaxis

Mouth and throat: Denies sore throat. Denies bleeding gums, ulcerations. Does not wear dentures. Last dental exam in May 2021.

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

Pulmonary: Denies shortness of breath, wheezing, or productive cough. Denies hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

Cardiovascular: Denies chest pain, palpitations, edema, irregular rhythms.

Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain.

Genitourinary: Menarche at 12.  LMP 7/3/22. Regular, 28 days cycle. Denies dysmenorrhea. Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria. Denies any history of STDs.

Nervous: Denies headaches, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.

Musculoskeletal: See HPI. Denies other joint pain, swelling, weakness, and changes in range of motion in other extremities.

Peripheral Vascular: Denies peripheral edema. Denies intermittent claudication.

Hematologic: Denies history of DVT/PE or previous blood transfusions.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.

Physical Exam:

General: 36F, A&O x3, sitting on exam table, wearing an Ace splint on her right wrist, in no acute distress. She is well groomed and well-developed for age. She does not appear ill.

Vitals:

  • BP(Seated): R – 123/76
  • P: 62, regular
  • R: 16breaths/min, unlabored
  • T: 98.6F (37.0C), oral
  • O2 Sat: 99% on room air
  • Height: 64 inches – Weight: 137lbs – BMI: 23.5 – Normal  

Skin: Warm and moist with good turgor throughout. Nonicteric. No lower extremity erythema and warmth. Nontender on palpation. No cyanosis or jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic, nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

  • Visual corrected – 20/20 OS, 20/20 OD, 20/20 OU from 6feet with pocket Snellen
  • Visual fields full OU.  PERRLA, EOMs intact with no nystagmus 
  • Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU. 

Mouth:

  • Lips: Pink and moist with no lesions
  • Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
  • Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact. 
  • Teeth: Good dentition with no obvious dental caries noted.
  • Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
  • Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.

Abdomen: Abdomen is symmetric with striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to light palpation, tender on deep palpation in epigastric and suprapubic regions. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Neurologic:

  • Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.

  • CN II-XII grossly intact.

  • Motor/Cerebellar: Full active ROM of all extremities without rigidity or spasticity. No atrophy, tics, tremors, or fasciculation.

  • Reflexes:
 RL RL
Brachioradialis2+2+Patellar2+2+
Triceps2+2+Achilles2+2+
Biceps2+2+BabinskiAbsentAbsent
Abdominal2+/2+2+/2+ClonusNegative
  • Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, no edema present. Pulses are 2+ bilaterally in upper and lower extremities.

Musculoskeletal:

Right hand and right wrist: mild edema over thenar eminence and over thumb joint. No ecchymosis, erythema, open wounds or deformity. Mild tenderness over wrist joint, thenar eminence, and thumb joint. No tenderness over anatomical snuffbox.

Decreased ROM of wrist due to pain. Dorsiflexion 50/70, palmar flexion 60/60 with mild pain, ulnar flexion 30/30 and radial flexion 20/20. Thumb flexion 20/60. Mild numbness over thenar eminence and tingling that radiates up ulnar side of arm. Sensation intact. Able to move all digits with hesitance and pain upon moving first digit.

Full active ROM of all extremities. Bilateral shoulder height symmetrical. No obvious deformities.

Strength 4/5 in right upper extremity and 5/5 left upper and both lower extremities.

Grip 3/5 right and 5/5 left.

Available Imaging:

  • MRI right wrist (6/17/20): minimal joint effusion, no acute fracture or dislocation.

  • MRI right hand (6/17/20): findings consistent with partial tear of ulnar collateral ligament. Soft tissue swelling over the dorsal aspect of the 1st interspace. No evidence of acute fracture or dislocation.

Assessment:

GG is a 36-year-old female denying past medical history who presents to our office for a right wrist injury while on duty.

Plan:

#Partial tear of right ULC

  • Not fit for duty.
  • Hand surgeon f/u in August.
  • OTC Tylenol as needed for pain, ice, Bengay over the affected region.
  • PT 2-3x week.
  • Continue using splint.
  • F/u in 2 weeks or earlier if needed. ED for worsening symptoms.