History

Identifying Data:

Full Name: Mr. B

Address: Not Disclosed

Age: 56 years

Date & time:11/18/2021 10:30 AM

Location: CitiMed JFK

Religion: Not disclosed

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

Chief Complaint: “Right wrist, right hand pain”

56 year old male, right hand dominant, DNATA, Dish Washer, presents for a follow up evaluation for a right wrist/hand IOD, sustained on 11/7/21, at 11:30 AM. Patient states he was at work, when he reached behind a machine and touched a hot part of the metal machine and burnt his right wrist. He was wearing vinyl gloves, with rubber gloves over them, and did not feel pain initially. When he removed his rubber gloves an hour later, he noticed the burn and skin “stripped off” and developed sudden, sharp, pain in his right wrist, and “white watery fluid” coming out. He denied head trauma, LOC, direct trauma, falls, bleeding. He applied “burn cream” and continued working another 3 hours until the end of his shift, with continued pain. He states the pain worsened, so he notified his supervisor on 11/9/21, and drove himself to this facility on 11/11/21, for further evaluation and treatment. He admits to similar burn injury on right wrist twice in the past, both times were treated by his PCP, without complication or chronic pain after. He states he is up to date on his tetanus vaccination.

Today, his right wrist/hand pain is 1/10, intermittent, dull, nonradiating, worse with palpation.

Denies pus, erythema, active bleeding, blisters, numbness, tingling, weakness in extremities, headaches, vision changes, neck pain, chest pain, sob, bowel/ bladder changes, nausea, vomiting, diarrhea, fever, abdominal pain. Patient ambulates to the office without any assistive devices.

Patient applies silvadene cream 1% once daily with relief. Patient states he has been wrapping his right wrist with gauze, with relief.

Patient is working full duty with discomfort. He would like to remain on full duty, while continuing treatment.

Xray Right Wrist (11/11/21): Question of soft tissue swelling along the radial aspect of the wrist. This should be correlated clinically. No fractures or dislocations. Prominent arterial vascular calcifications volar to the included portion of the mid to distal forearm.

Xray Right Hand (11/11/21): Question of an area of cortical disruption involving the proximal third of the terminal phalanx of the thumb located relative to its medial aspect. As noted above, this may simply relate to a nutrient canal or represent a spurious finding. A CT scan would be helpful if felt to be clinically warranted. Fullness of the soft tissues along the radial aspect of the distal forearm. Arterial vascular calcifications in the volar aspect of the radial portion of the distal forearm, atypical for age

Past Medical History:

Type 2 diabetes mellitus,

hypertension,

hyperlipidemia

Past Surgical History:

2012 Left foot fifth toe amputation

Medications:

Metformin 500 mg, twice daily

Lisinopril 40 mg, once daily

Chlorthalidone 25 mg, once daily

Rosuvastatin 40 mg, once daily

Silvadene cream 1%

Allergies:

NKDA

Family History:

No pertinent family history

Social History:

Mr B is a 56 year old male living in a house with his wife. Denies history of smoking, or drug use. Drinks alcohol once per month.

 Works as dishwasher for DNATA

Sleep-Sleeps 6 hours per night

Review of Systems:

General-See HPI

Skin, hair, nails – See HPI

Eyes – Denies lacrimation, erythema

Ears – Denies discharge. No hearing aids.

Nose/sinuses – Denies rhinorrhea, congestion, epistaxis

Mouth/throat – Denies sore throat, voice changes.

Neck – Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system –Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system –Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system- Denies abdominal pain, nausea, vomiting, diarrhea

Genitourinary – Denies frequency, dysuria, incontinence, nocturia, hematuria

Nervous –Headache. Denies seizures, loss of consciousness, problems with walking or balance, dizziness

Musculoskeletal– See HPI

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions

Vital Signs

HR: 80 BPM, regular

BP 138/82 L arm sitting

RR: 17 breaths/minute, unlabored

Temp: 98.6 degrees F oral

O2 Sat: 99% on room air

Ht 5’8’’

Wt 210 lbs

BMI 31.9

Physical Exam:

General: Adult male, well groomed, well nourished, non-toxic appearing, in no acute distress. Appears stated age.

Skin:   warm & moist, good turgor. capillary refill <2 seconds throughout. \

Head: normocephalic, atraumatic,

Ears – external ears symmetrical.

Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. pupils equal, round, reactive to light and accommodation, EOMI. 

Oral Cavity: mucosa moist.

Chest – Symmetrical, no deformities, no evidence trauma. Nontender. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. No nasal flaring or retractions

Lungs – Clear to auscultation bilaterally, no adventitious sounds, wheezes or rhonchi.

Heart:   RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: No ecchymosis or varicosities. Abdomen soft throughout, nondistended, nontender, no CVA tenderness

Musculoskeletal:

Right wrist and right hand- Healed partial thickness burn on right lateral wrist. Hyperpigmentation right lateral wrist. No ecchymosis, edema. Right lateral wrist with 1cm x 1cm firm, tender, nodule. No anatomic snuffbox tenderness.

Full ROM right wrist. Dorsiflexion 70/70, Palmar flexion 80/80, Ulnar flexion 30/30, Radial flexion 20/20. Full ROM all fingers. Grip 4/5 right. Grip 5/5 left.

Full ROM all other extremities. Strength- 5/5 both upper and lower extremities.

Neuro: alert and oriented, cranial nerves 2-12 grossly intact, gait normal, sensory exam intact.

Extremities: no clubbing, cyanosis, or edema.

Peripheral Pulses: 2 +
bilaterally.

Psych: alert, oriented, cooperative with exam, speech clear

Assessment:

56 year old M with past medical history Type 2 DM, HTN, HLD presents for follow up after burning his right wrist on 11/7/21. The burn is healing well with no signs of infection full ROM of hand and wrist, there is a new firm, tender, nodule on right lateral wrist and decreased grip strength.

Partial thickness burn – healing well

Ganglion cyst vs rheumatoid nodule vs lipoma vs tophus vs neoplasm

Plan:

• Continue Silvadene Cream, 1 %, 1 application to affected area, Externally, twice a day
• Clean daily with gentle soap and water. Dry thoroughly. Apply silvadene cream to wound daily. Cover with clean gauze.
• MRI right wrist referral given to r/o tear and evaluate mass, scheduled for tomorrow
• Duty Status: Full duty
• 25% temporary disability,
• Work Status: working
• Analgesia
  • OTC Tylenol and Arnica gel and ICY HOT,
  • Ice in a towel
• Physical therapy, acupuncture, and HBOT 3 times a week for 4 weeks, to decrease pain, and improve ROM
• Return in 1 week for followup
• Nearest ER for worsening symptoms