Identification:

• Name: H.G
• Sex: M
• Race: Hispanic
• Nationality:
• Age: 33
• Marital Status:
• Address:
• Religion:

Informant:

• Source of hx: Self
• Competency: Competent

 

Referral Source:

CC: “ My right arm hurts” x 5 hours

HPI:

33 y/o male with no pmhx presents to the ER with right arm pain s/p fall off a bike 5 hours ago. Pt states that he was riding his bike in the rain when the front wheel of his bike got stuck in a pothole. Pt states that he fell off the bike and landed on his right arm. Pt states that pain is sharp, localized to the right arm, constant, not alleviated by anything, and a 10/10. Pt states that he does not remember if he saw bone eroding out his skin at the time of injury. Xray in the ER was done of the right arm found to have a midshaft radial ulnar fracture. Pt has splint placed by ED staff. Pt denies numbness and tingling of the right arm.

Pmhx:

• Non

Past surgical hx:

• None

Medications:

• None

Allergies:

• No known food, environmental or drug allergies.

Family hx:

• None

Social Hx:

• Denies using drugs, tobacco, alcohol use, recent travel.

General:

• Denies fever, chills, fatigue, loss or gain of weight, N/V, diaphoresis, loss of appetite and night sweats.

Skin, hair and nails:

• Denies change in texture to skin, hair and nails, excessive dryness, discolorations, pigmentations, sweating, moles/rashes, pruritis, and change in hair distribution.

Eyes:

• Denies visual disturbances, lacrimation, photophobia, itching, corrective lenses, blurriness, and discharge. Denies wearing glasses.

HENNT:

• Denies headaches, vertigo, head trauma
• Denies hearing loss, tinnitus, pain, discharge, wearing hearing aids
• Denies epistaxis, discharge, obstruction, rhinorrhea, stuffiness, sneezing, allergies
• Denies swelling/lumps, stiffness, or decreased ROM
• Denies sore throat, neck pain, hoarseness, bleeding in mouth/throat, sore tongue, mouth ulcers, voice changes or wearing dentures.

Pulmonary:

• Denies cough, wheezing, SOB, pain on inspiration, hemoptysis, orthopnea, cyanosis, PND, clubbing, or any history of asthma.

Cardiovascular:

• Denies CP, HTN, edema, palpitations, irregular heartbeats, syncope, claudication, murmurs, and orthopnea.

 

Gastrointestinal:

• Denies indigestion, intolerance of foods, N/V, diarrhea, jaundice, bleeding (oral or anal), hemorrhoids, constipation any change in BM, dysphagia, pyrosis, flatulence, blenching or burping, rectal bleeding and abdominal pain.

Genitourinary:

• Denies frequency, nocturia, urgency, dysuria, oliguria, lesions, discharge, hematuria, pyuria, dyspareunia, any flank pain and any abdominal pain.

Nervous System:

• Denies seizures, headache, LOC, loss of strength, change in cognition, mental status, memory, ataxia, sensory disturbances, syncope, slurring of speech, focal weakness, neck stiffness, any decrease in sensation, and tingling.

MSK:

• Admits to right muscle and bone pain

Peripheral Vascular System:

• Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System:

• Denies new or known bruising, bleeding, petechiae, purpura, blood transfusions, lymph node enlargement, hx of DVT/PE and anemia

Endocrine:

• Denies polyphagia, polyuria, polydipsia, intolerance to heat/cold, goiter, excessive sweating or hirsutism.

Psychiatric:

• Denies depression/sadness, suicidal ideation, anxiety, seeing a mental health specialist, memory deficits, OCD, and taking medication for mental illness.

Physical

General:

• Male, well nourished, in no acute distressed. Acceptable hygiene appears age stated. Is alert and cooperative

Vitals:

• BP: R
  1. Seated 128/88
• R: 17 breaths/min, unlabored
• P: 92 beats/min, regular
• T: 9 degrees F (oral)
• O2 Sat: 100% Room air
• Height 5 feet 6 inches   Weight 192 lbs.   BMI: 30.1

Skin:

• Laceration over the right arm, irrigated by ED staff

Head:

• No scars, bumps, trauma, tenderness to palpation, normocephalic, atraumatic

Hair:

• Average quantity and distribution

Nails:

• No clubbing, cap refill <2 seconds throughout.

Eyes:

• symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white, no icterus; conjunctiva & cornea clear. Visual fields full OU. PERRLA. EOMs full with no nystagmus.

Ears:

• Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. Auditory acuity intact to whispered voice AU.

Nose:

• Symmetrical / no obvious masses / lesions / deformities / trauma / discharge.   Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation.   No evidence of foreign bodies.

Sinuses:

• Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips:

• Pink, moist; no evidence of cyanosis or lesions.   Non-tender to palpation.

Mucosa:            

• Pink; well hydrated.   No masses; lesions noted.   Non-tender to palpation. No evidence of leukoplakia.

Palate:

• Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth:

• Decent dentition / no obvious dental caries noted.

Gingivae:

• Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue:

• Pink; well papillated; no masses, lesions or deviation noted

Oropharynx:

• Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils absent, no hx of removal. Uvula pink, no edema, lesions

Neck:

• Good ROM. Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. No stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid:

• Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest:

• Symmetrical, no deformities, no evidence trauma.   Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1.   Non-tender to palpation.

Lungs:

• Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical.. No adventitious sounds. No rales, Rochi, or wheezing heard.

Heart:  

• Carotid pulses are 2+ bilaterally without bruits. RRR; S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen:

• Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of hepatomegaly or splenomegaly. No masses noted.   No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Peripheral Vascular:

• The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Mental Status:

• Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves:

• I – Intact no anosmia.
• II- VA 20/20 bilaterally. Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good. Corneal reflex not tested.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Motor/Cerebellar:

• Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone throughout. No atrophy, tics, tremors or fasciculations.

Sensory:

• Intact to light touch,.

Meningeal Signs:

• No nuchal rigidity noted.

MSK LE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted No evidence of spinal deformities.

MSK UE:

• RUE noted to have Long arm splint in place

Assessment:

• All clinical findings indicate right midshaft radius and ulna fracture

Plan:

• Right midshaft radius and ulna fracture
  1. Open Reduction internal fixation
  2. Ancef and gentamycin given in ED
  3. Explain procedure to patient including all risk, benefits and alternatives
  4. Book case for OR