CC
Sara is a 41-year-old female here today complaining of right wrist pain.
HPI
The patient had prior trauma to her wrist, resulting in a right radial fracture, treated with surgery by Dr. Eberhart in February of 2014. Since then, she tells me, once she recovered from that, she had been doing reasonably well. About a week and a half ago, she says she fell on her wrist. She tripped. She immediately felt pain, as well as there was swelling in the right wrist as well. She went to an urgent care and I do not have notes from that visit. Reportedly, x-rays were done and were normal. She was given some tramadol for pain, which she said did not help at all and she is no longer taking it and was recommended to follow up with orthopedics. She actually has an appointment with Christina Scardina, PA this week on Thursday, September 17th. She said that yesterday, she had a new injury to her wrist and when she called the orthopedics specialist, they requested that she see her …show more content…
Social History
She is a tobacco user. She tells me she is sober.
O
Vital Signs
Temperature: 98.2. BP: 116/72. HR: 74. R: 14. W: 140.
General
A well-developed, well-nourished female seated comfortably in the exam room. She does become tearful when discussing the amount of pain that she is in.
Extremities
Her right upper extremity was examined. There is perhaps just very mild swelling at the wrist. She does complain of pain along the ulnar side of the wrist and there is tenderness to palpation there. She has decreased range of motion with flexion and extension as well as inversion and eversion at the wrist due to pain, per her report. She is able to fully flex and extend her fingers. There is no pain there. There is no pain at the elbow or as I move along distally to the forearm, until I get just to the wrist itself. There is no pain over the metacarpal bones, normal sensation throughout. There is less than two second cap refill.
Sara is a 41-year-old female here today complaining of right wrist pain.
HPI
The patient had prior trauma to her wrist, resulting in a right radial fracture, treated with surgery by Dr. Eberhart in February of 2014. Since then, she tells me, once she recovered from that, she had been doing reasonably well. About a week and a half ago, she says she fell on her wrist. She tripped. She immediately felt pain, as well as there was swelling in the right wrist as well. She went to an urgent care and I do not have notes from that visit. Reportedly, x-rays were done and were normal. She was given some tramadol for pain, which she said did not help at all and she is no longer taking it and was recommended to follow up with orthopedics. She actually has an appointment with Christina Scardina, PA this week on Thursday, September 17th. She said that yesterday, she had a new injury to her wrist and when she called the orthopedics specialist, they requested that she see her …show more content…
Social History
She is a tobacco user. She tells me she is sober.
O
Vital Signs
Temperature: 98.2. BP: 116/72. HR: 74. R: 14. W: 140.
General
A well-developed, well-nourished female seated comfortably in the exam room. She does become tearful when discussing the amount of pain that she is in.
Extremities
Her right upper extremity was examined. There is perhaps just very mild swelling at the wrist. She does complain of pain along the ulnar side of the wrist and there is tenderness to palpation there. She has decreased range of motion with flexion and extension as well as inversion and eversion at the wrist due to pain, per her report. She is able to fully flex and extend her fingers. There is no pain there. There is no pain at the elbow or as I move along distally to the forearm, until I get just to the wrist itself. There is no pain over the metacarpal bones, normal sensation throughout. There is less than two second cap refill.