CHIEF COMPLAINT: Arm injury, left.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female with history of diabetes, Alzheimer disease, comes in today with the above complaint. Apparently, she was chasing a child about the house this afternoon when she lost her footing and slipped and fell on her outstretched left arm. She did not hit her head, had no loss of consciousness, and her son states he was in the other room when he heard a thud, quickly went into the room within about 10 seconds and found his mother laying on the ground, on her left side, but has been at her baseline mental status ever since.
She was awake, alert and oriented when he went into the room. This happened earlier this afternoon. She was complaining only of wrist discomfort as well as a slight skin tear on her left elbow at the time. The patient states in the ensuing several hours her wrist has gotten significantly swollen and bruised and so they brought her in for evaluation. The patient is right-hand dominant. She denies any other injury or pain.
No headache, dizziness or syncopal episodes since the fall. She at no time had any sort of chest pain or shortness of breath. She and her son both state that they feel it was a simple slip and fall type of injury. She denies any numbness or tingling to the extremity but is having significant pain to her left wrist. She thinks her last tetanus is up-to-date.
REVIEW OF SYSTEMS: As above. Otherwise, negative.
PAST MEDICAL HISTORY:
1. Alzheimer’s disease.
2. Diabetes.
3. Hard of hearing.
4. Bilateral hip replacements.
MEDICATIONS:
1. Erycette.
2. Lipitor.
3. Klor-Con.
4. Zebeta.
5. Lodine.
6. Lasix.
7. Celexa.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She is visiting her son here.
PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the ED today, temperature 98.6, blood pressure 104/64 with a pulse of 72, respiratory rate 18, O2 saturations 96% on room air.
GENERAL: A (XX)-year-old thin Hispanic female who is uncomfortable but in no acute cardiopulmonary distress. She is awake, alert and oriented x3. She is pleasant and cooperative with the exam.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Her extraocular muscles are intact. No nystagmus.
NECK: Supple, nontender, without midline cervical spine tenderness.
HEART: Regular rate and rhythm. Pulses are symmetric and intact to the upper and lower extremities.
LUNGS: Clear. She is breathing easily.
EXTREMITIES: Examination of the left upper extremity reveals obvious deformity consistent with a Colles fracture with a large amount of ecchymosis to the anterior aspect of the distal forearm. Diffuse tenderness over the entire wrist, particularly at the distal radius without any particular tenderness over the carpals or into the hand. She does have a slight skin tear approximately 1 to 1.5 cm in diameter over the lateral aspect of the elbow, but she is able to flex and extend the elbow without any discomfort there. No bony tenderness in the elbow itself. She is able to move the shoulder as well without any discomfort. No tenderness or bony step off at the collar bone. She is able to move all fingers of the left hand. Her capillary refill is brisk. Pulses are symmetric and intact in the upper extremities. Sensation is intact throughout. There is no evidence for a tendinous injury to the hand associated with this. Median nerve function is appropriate at this point.
EMERGENCY DEPARTMENT COURSE: Here in the ED, her nursing notes are reviewed. She was given Vicodin and Motrin p.o. for her discomfort. She was given an ice pack. The skin tear was cleaned with saline, dressed with Adaptic. We did debride the wound edge by clipping off a bit of the torn skin before cleaning and dressing the wound and Adaptic with a Webril dressing was then applied and the patient tolerated this well.
X-ray of the left wrist was read by the attending radiologist and showed a comminuted but fairly nondisplaced fracture of the distal radius with an associated ulnar styloid fracture.
The patient here was splinted with a sugar tong splint and given a sling. Copies of her x-rays were called for and the family will pick those up at medical records on their way out. Dr. Jane Doe has seen this patient and agrees with the following assessment and plan.
ASSESSMENT: Left wrist Colles fracture.
PLAN:
1. The patient will be discharged home.
2. She is to rest, ice, elevate.
3. Vicodin, dispense 15 as needed for pain.
4. She is started on Colace while on the Vicodin.
5. Follow up with Orthopedics within a week. She is to call on her return home to her orthopedist.
6. Splint until seen by Orthopedics.
7. Daily range of motion exercises to her left shoulder while she is in the sling.
8. Pick up copies of x-rays of medical records.
9. Otherwise, return as needed.
The patient and her family understand and agree with this plan.
DISPOSITION: Home in stable condition.
