TIME SEEN
Has been chief he IK, PRE and EOMI, medical record, #97247 to 15-year-old male. Chief complaint
school right hand pain and swelling. Capillary refill less than 21527, placed in 1647, seen at 1700 hours
on 03/12/2008 15-year-old male arrives here with mother right-handed individual and I go to the room.
The mother is asking nurses. This patient has something for pain. At 1315 hours, stated patient, himself
was at school struck a close locker with a closed fist pain in the lateral aspect of his right hand at 3/10 at
rest pressure in sensation and tight in sensation without radiation increased to an 8/10 with movement,
especially extension of the fingers of his right hand. Negative for numbness, tingling, positive for swelling
109/70 9798314. Oxygen saturation 96%. Past medical history significant for possible Marfan's
syndrome. Pectus date nondilated aorta mitral valve 3 GERD area orbital fracture strep throat. He is a
smoker 2 to 3 cigarettes day. No PE classes in school unknown last tetanus immunization. General
appearance patient is alert, answers questions readily, appears to have logical thought process.
Integumentary system skin is pink, warm, and dry. Turgor good. Capillary refill less than 2 seconds
superficial abrasions noted to the lateral aspect of his right hand on its dorsal aspect soft tissue swelling
noted in that area also on the fifth metacarpal pain with palpation in that area. Musculoskeletal able to
flex and extend digits of right hand 55 strength equal wrist flexion and extension of the 20 right and left.
No cyanosis noted. Given ibuprofen 800, Tylenol 650 at the time, I go see that an x-ray has been read by
the radiologist as to transverse fracture of the midshaft of the fifth metacarpal with mild medial
angulation. Mother is shown the x-rays C and S checked after the combination ulnar gutter volar splint on
the right. It is with capillary refill less than 2 seconds. Sensation is intact. Able to move the digits of his
right hand 1737 they are discharged. He has a swelling. Diagnosis one acute fracture, right fifth
metacarpal. Discharge instructions ibuprofen 800 mg 3 times a day with food p.r.n. pain or swelling 20
prescribed. Tylenol 650 mg every 4 hours p.r.n. pain, Bactrim 4000 mg Tylenol day, caution is in the
Vicodin. Vicodin 55 hundredths, one every 4 hours p.r.n. pain, not relieved by ibuprofen, 20 prescribed
caution sedation. No smoking, assess tetanus immunization status is up-to-date within 48 hours as
needed and splint on sling when up otherwise elevate right hand as much as possible. Ice 15 minutes on
and 15 minutes off p.r.n. pain or swelling. Ice 0 psych pelvic rock increase in within 7 days for a recheck
of her observe for sensation change or weakness and return hours.
JOHN C. LINCOLN HOSPITAL --- NORTH MOUNTAIN
This medical report may not be re-released without proper authorization.
*Dates and Times in EST for Printed and Faxed Documents.1
Page 1 of 1