Sunday, April 12, 2009

Josh's History and Physical Examination

CHIEF COMPLAINT
1. Subungual hematoma of the 1st finger, left hand.
2. Status post dyspilectomy and clipping. See link for details.

HISTORY OF PRESENT ILLNESS
The patient is a 6-year-old white male who was brought in by his mother and seen in consultation for ecchymotic discoloration and mild tenderness of the subungual region of the distal phalanx of the 1st finger, left hand, secondary to blunt trauma. There is an area of subcutaneous bleeding in the proximal portion of the nail that measures approximately 4.5 x 4 cm. Patient is no longer experiencing any significant pain at rest. His mother states that she has no idea what caused the bleeding. Patient himself states "I'm just not that good with a hammer."

PAST MEDICAL HISTORY
Past medical history is positive for head injury with epidermal sutures.

SOCIAL HISTORY
Mother's ambivalence is probably due to the fact that the patient lives with his parents, 6 brothers and 2 sisters. He does not drink or smoke. He does however work, vacuuming the floor in his family's home.

MEDICATIONS
None.

ALLERGIES
None.

PHYSICAL EXAMINATION
GENERAL: Patient is a well-nourished, well-developed white male in no acute distress.
HEENT: Pupils are round and reactive to light. Extraocular muscles are intact. Sclarae are clear, nonicteric. Tympanic membranes intact. Nares patent. Oropharynx clear.
NECK: Supple, without adenopathy. No carotid bruits are heard.
LUNGS: Lungs clear to auscultation. No rhonchi, rales, or wheezing.
CHEST: Heart is regular rate and rhythm, without murmur.
ABDOMEN: Slightly distended secondary to lunch x2.
EXTREMITIES: Extremities without edema. Regular pulses bilaterally. There is an ecchymotic discoloration over the dorsum of the base of the distal phalynx just above the lunula, measuring approximately 4.5 x 5 cm. No onycholysis is noted. No apparent avulsion of extensor tendon.
RECTAL: Deferred.

ASSESSMENT
1. Subungual hematoma of the left distal phalynx of the 1st finger of the left hand, with good hemostasis.
2. Status post dyspilectomy and clipping.

PLAN
Recommend treating the patient with Children's Tylenol 80 mg 1 tablet p.o. t.i.d. p.r.n. pain. It is felt that since there is no longer any significant pain, trephination at the base of the nail is not recommended at this time. Mother will bring him back if there is any further indication of infection or swelling. Otherwise, followup in my office in 2 weeks' time.

6 comments:

bonnie jack said...

hehe. someone's been spending too much time listening to medical transcription tapes.

Mary (MEM) said...

Time to get out my dictionary- very impressive use of medical terminology, Becky!

Erika said...

only way to contact you what is your email mine is erikarichan@gmail.com I want to talk with you I am so interested about homeschooling for my girls. please let me know What a wonderful surprise!!!

Anonymous said...

First his haircutting mishap, now this--what an adventurer Josh is! Great medical transcripting too, I need to get a Merck index or something to help translate. This only lets me post as Anonymous but this is Grace talking.

Atzimba said...

Wow, I am impressed.
How are things going with transcription?
Well, it looks that NY will be; at least as of now. But we need to be 'there' (wherever that is) in three or so weeks.
But I know it is only a stop there for us or elsewhere. We know the destination.
What are the plans for your blog makeover or something. Still miss you! Wait! You are having a b-day this week.... yeah!

Atzimba said...

YEAH!!! Love the new look! Congratulations!