CC: “I have right hand/wrist pain x4 months”

HPI:

29 y/o female with no past medical history presents to the clinic for f/u evaluation for IOD of her right wrist and hand sustained 6/10/20. Pt works for American Airlines as a Fleet Agent, and as she was grabbing luggage from the belt loader with her left hand, she accidentally hit her right hand as she threw the luggage into her stock area. Patient states she was in immediate pain and stopped working. Patient states she reported the injury to her supervisor and was referred to this facility. That same day, she drove herself to this clinic for further evaluation and treatment. She denies any LOC, head trauma or any open wounds. 

Today her right hand and wrist pain is rated 6/10, constant, throbbing, worse with movement and gripping. Admits to pain radiating from the wrist to the interphalangeal joint of the thumb. Also admits to numbness and tingling at the thenar eminence as well as the lateral aspect of her right thumb. She reports using a splint with mild relief and takes Tylenol Extra Strength 1 tab 2x daily with relief. Patient was evaluated by the hand surgeon, who gave her a splint and to be worn at all times. Patient was placed on a prednisone taper, and is no longer taking it. Patient was last seen by the surgeon on 8/31 s/p steroid injection, but reported increased pain and swelling. PT goes to PT 2x a week. Denies headaches, vision changes, neck pain, chest pain, n/v/d, fever, abdominal pain.

PMH:

none

Surgical History:none

Allergies: NKDA

Meds: tylenol extra strength prn

Family History: Mother alive.

Father alive

Social history: non smoker. ETOH  “social drinking.” Works for American Airlines as a Fleet Agent

ROS:

Constitutional: Denies weight loss, fatigue, night sweats

Head: denies LOC, headaches, trauma, changes in vision

Neurologic: See HPI. denies syncope, focal weakness.

Eyes: denies itching, tearing, visual acuity issues.

ENT: denies tinnitus, hearing loss, vertigo, stuffiness, sore throat or neck pain.

Cardiac: Denies palpitations, murmurs, chest pain.

Pulmonary: Denies cough, hemoptysis, fibrosis.

Hematology: Denies bruising, petechiae, or purpura.

Skin: Denies edema, bruises or excoriations.

GI: Denies N/V/D, jaundice, constipation.

GU: Denies urgency, dysuria, inguinal hernias, polyuria or nocturia.

Musculoskeletal: see HPI.

Psychiatric: denies stress, anxiety, depression or mood changes.

Physical Exam

Vitals: 126/78 pulse: 67 Resp: 18 SpO2: 98% RA. Temp 98.1

General: A&Ox3. In mild distress, well developed, good hygiene, appears stated age.

Head: Normocephalic, no scars or lesions or trauma.

Eyes: Symmetrical. Iris brown. No erythema over sclera and conjunctiva. No ptosis, icterus. EOMI without nystagmus. PERRLA. Fundoscopic exam: Vessels sharp, no cotton-wool spots or papilledema. Visual acuity deferred.

Ears: Symmetrical. No TTP over tragus, lobe or helix. AU-EAC unobstructed. TMs pearly gray, no injection or bulging TM noted.

Nose: Septum midline. Patent airway. No rhinorrhea. Inferior turbinates observed. No hematoma, discharge or foreign body.

Mouth/Throat: Teeth intact and no evidence of loose teeth or dentures. Tongue, uvula midline. Tonsils present grade 2. Uvula midline. No PND.

Neck: Supple, no palpable goiter or TTP.

Lymph nodes: No palpable lymphadenopathy. No TTP.

Lungs: No adventitious lung sounds.

Heart: RRR without gallops, skips or murmurs. Audible S1 S2.

Abdomen: Bowel sounds heard throughout, no general or rebound tenderness.

Gentourinary: examination deferred. DRE deferred.

Skin: Noted clubbing of fingers. No edema, ecchymosis or rashes.

Musculoskeletal: Right hand and right wrist: mild edema over thenar eminence and over thumb joint. No ecchymosis, erythema, open wounds or deformity. Mild tenderness over wrist joint, thenar eminence, and thumb joint. No tenderness over anatomical snuffbox. Decreased ROM of wrist due to pain. Dorsiflexion 50/70, palmar flexion 60/60 with mild pain, ulnar flexion 30/30 and radial flexion 20/20. Thumb flexion 20/60. Mild numbness over thenar eminence and tingling that radiates up ulnar side of arm. Sensation intact. Able to move all digits with hesitance and pain upon moving first digit. 

Mental status: Appropriate memory, with adequate repetition, no aphasia or dysarthria.

Neurological exam: Cranial nerves: II-XII grossly intact. 

Assessment/Plan

MRI right wrist (6/15/20): minimal joint effusion, no acute fracture or dislocation.

MRI right hand (6/15/20): findings consistent with sprain of ulnar collateral ligament. Soft tissue swelling over the dorsal aspect of the 1st interpace. No evidence of acute fracture or dislocation.

• Pain in right wrist
• Pain in right hand
• Sprain of right wrist and hand

Not fit for duty. Hand surgeon f/u in October. OTC Tylenol as needed for pain, ice, Bengay over the affected region. PT 2-3x week. Continue using splint. F/u in 2 weeks or earlier if needed. ED for worsening symptoms.