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Medical Transcription

HISTORY OF PRESENT ILLNESS:

I am seeing Marsha today for evaluation for her right wrist. The patient fell on her right wrist on 03/20/11. It was after some rain, she was resting on a stick and fell on to both outstretched hands. She also fell on to her right knee, which is a total knee replacement ----- did and she also injured her left ankle. The patient was placed into a lace-up splint for the left ankle. The right wrist was treated with a thumb spica brace. She had x-rays taken at ------ Hospital, which she brings with her today. Because of that, the patient is here to be seen.

PHYSICAL EXAMINATION:

Exam today shows the patient in no distress. There is some swelling around the right wrist. She does have some mild reproducible tenderness at the right wrist radial snuffbox. The right wrist range of motion was not checked but it looks to be slightly limited. She doesn’t have any significant tenderness around the first extensor compartment and no significant tenderness around the right thumb CMC area.

RADIOGRAPHS:

X-rays – Outside x-rays from ------- Hospital are reviewed, they are from 03/21/11. They do not demonstrate any fracture to the scaphoid. There is some early arthritis of the right thumb CMC area. The lateral x-ray looks to be normal. There is some sclerotic area through the mid portion of the scaphoid but again no obvious fracture. The cortical lines look to be well aligned. Again views also show a well-aligned scaphoid with no obvious fracture.

IMPRESSION:

Patient with a right wrist sprain, possible injury to the scaphoid.

TREATMENT PLAN:

The patient is going to remain in her thumb spica splint. I am going to see her back next week with x-rays out of her splint to confirm that she does not have a scaphoid fracture. Again, if she persists with pain and she has two negative x-rays, we would then consider a CT scan or MRI.

Skills: Editing, Health, Medical Writing, Transcription

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Project ID: #1242732

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