Scottkuntz1
Contributor
CHIEF COMPLAINT: Reinjury, left wrist.
HISTORY OF PRESENT ILLNESS: This is a 41-year-old right-hand dominant male who had had a dorsal triquetral fracture treated last fall by Dr. Demuth with a splint. He reinjured it yesterday. He slipped on some ice, fell on his left wrist and hyperextended it. He had immediate pain. He got a wrist strap at Rite-Aid which he has been wearing. It throbs at night.
REVIEW OF SYSTEMS: The patient's past medical history, social history, family history, and detailed review of systems were reviewed and recorded.
PHYSICAL EXAMINATION: He is a well-developed, well-nourished male in no acute distress. He is alert and oriented X 3. He is pleasant, cooperative, and a good historian. Posture and gait is normal. Range of motion of the neck does not reproduce any upper extremity symptoms. The skin has normal color and temperature. Distal pulses are intact. Sensory exam is normal. Motor exam of the hand is normal.
To visual inspection he has some dorsal soft tissue swelling. He has exquisite tenderness of the dorsal capsule, not much tenderness volarly. There is no tenderness in the snuffbox. There is no tenderness at the MP joint. He has a partial amputation of his thumb from an old gunshot injury. Skin color and temperature is normal. Slight pain with ulnar deviation.
DIAGNOSTIC TESTS: X-rays from Harrisburg Diagnostic from January 22nd show a tiny avulsion fracture dorsally off the triquetrum. No sign of any ligament separation. The scaphoid looks normal.
IMPRESSION: He has a recurrent avulsion fracture of the dorsal triquetrum with ligamentous sprain.
PLAN: Since this is his second reinjury to this, I have elected to go with a full short-arm fiberglass cast for more rigid immobilization. Follow up in three weeks for cast off repeat x-ray. If his tenderness has subsided, I will switch him to a wrist brace at that time.
Here is the complete note from the doctor he is still global for the same fracture 6 days left can you start a new global because he is definitely doing definitive care for this fracture with casting and coming back again for xrays? Thanks.
HISTORY OF PRESENT ILLNESS: This is a 41-year-old right-hand dominant male who had had a dorsal triquetral fracture treated last fall by Dr. Demuth with a splint. He reinjured it yesterday. He slipped on some ice, fell on his left wrist and hyperextended it. He had immediate pain. He got a wrist strap at Rite-Aid which he has been wearing. It throbs at night.
REVIEW OF SYSTEMS: The patient's past medical history, social history, family history, and detailed review of systems were reviewed and recorded.
PHYSICAL EXAMINATION: He is a well-developed, well-nourished male in no acute distress. He is alert and oriented X 3. He is pleasant, cooperative, and a good historian. Posture and gait is normal. Range of motion of the neck does not reproduce any upper extremity symptoms. The skin has normal color and temperature. Distal pulses are intact. Sensory exam is normal. Motor exam of the hand is normal.
To visual inspection he has some dorsal soft tissue swelling. He has exquisite tenderness of the dorsal capsule, not much tenderness volarly. There is no tenderness in the snuffbox. There is no tenderness at the MP joint. He has a partial amputation of his thumb from an old gunshot injury. Skin color and temperature is normal. Slight pain with ulnar deviation.
DIAGNOSTIC TESTS: X-rays from Harrisburg Diagnostic from January 22nd show a tiny avulsion fracture dorsally off the triquetrum. No sign of any ligament separation. The scaphoid looks normal.
IMPRESSION: He has a recurrent avulsion fracture of the dorsal triquetrum with ligamentous sprain.
PLAN: Since this is his second reinjury to this, I have elected to go with a full short-arm fiberglass cast for more rigid immobilization. Follow up in three weeks for cast off repeat x-ray. If his tenderness has subsided, I will switch him to a wrist brace at that time.
Here is the complete note from the doctor he is still global for the same fracture 6 days left can you start a new global because he is definitely doing definitive care for this fracture with casting and coming back again for xrays? Thanks.
