Episodic Visit: Musculoskeletal Focused Note Essay

Episodic Visit: Musculoskeletal Focused Note Essay

Episodic Visit: Musculoskeletal Focused Note Essay

Episodic/Focus Note Template

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 Patient Information:

CC (chief complaint): “My left pinky has gone crooked.”

HPI: JD is an 18-year-old Hispanic male who came to the office for evaluation and treatment because of an injury to his left fifth digit 2 days ago. He was going through his file cabinet the night before admission when he felt a tug at his left fifth digit. His finger has swollen at the distal interphalangeal joint since then. He reports that there was a little pain in the finger just after the incident, but this subsided when he tried over-the-counter Advil tabs. His main concern is that the mild swelling around the joint has not subsided, and he cannot keep his finger straight. He reports no swelling, pain, or deformity in the right fingers and other fingers of the left hand. He is not diabetic and has no family history of arthritis or any joint diseases. He reports no muscle aches, back pain, joint pain, or stiffness.

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Location: his pain was localized to the little finger

Onset: 2 days ago

Character: cramping,

Associated signs and symptoms: no bleeding, no discharge

Timing: constant, but currently, the pain is not there following the use of Advil 

Exacerbating/ relieving factors: worse on finger movement and relieved by painkillers and rest

Severity: 3/10 pain scale

Current Medications: He has used over-the-counter Advil but is currently on no medications.

Allergies: He has no known allergies to foods or medications

PMHx: He denies any hospitalizations in the past. No history of surgery is also reported. He received his flu shot 6 months ago.

Soc Hx: He enjoys playing chess and badminton. He takes coffee, daily, at least one mug per day. He also takes diet coke occasionally. He ensures his seat belt is on while driving.

Fam Hx: He is the second born in a family of three. His parents are alive and well. There’s no known history of chronic illnesses in the family, both nuclear and extended.

ROS:

GENERAL: No fever, no fatigue, now weight loss, no night sweats.

HEENT: Eyes: No visual loss, no hearing loss, no loss of taste, no blurred vision, no congestion, no sore throat.

SKIN: No skin rash, no yellowing, no scaling.

CARDIOVASCULAR: No palpitations, no chest tightness, no left-sided chest pain, no edema.

RESPIRATORY: No cough, no difficulty in breathing.

GASTROINTESTINAL: No abdominal distension, no yellowing of eyes, no nausea, no vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: no burning on urination, no history of STIs, no penile itchiness or ulcers, no incontinence.

NEUROLOGICAL: No headache, no dizziness, no numbness, no tingling sensation in hands or feet.

MUSCULOSKELETAL: No muscle aches, back pain, joint pain, or stiffness.

HEMATOLOGIC: No bleeding, no bruising.

LYMPHATICS: No swellings in the armpit, groin, or neck

PSYCHIATRIC: his mood is subjectively ‘good’.

ENDOCRINOLOGIC: No excessive sweating, no tremors, no intolerance to heat or cold.

ALLERGIES: No history of asthma, rhinitis, or allergic reactions0 in the past

O.

Physical exam:

General examination: the patient is in good general condition, with no distress, no pain, no pallor, no cyanosis, no edema, and no lymphadenopathy.

Blood pressure 110/79mmHg, HR 76 beats per minute, BMI = 22.3 kg/m³, temperature = 98.8⁰F, pain scale is 1/10, oxygen saturation = 100% in room air

Head: no bruises, no masses.

Eye: pupils are bilaterally round equal and reactive to light, and extraocular movements are intact

Ear: No discharge, hearing equal bilaterally, normal Rinne’s and Weber’s tests

Nose: nostrils clear, no septal deviation, no discharge, no congestion

Throat: no tonsillar hypertrophy, no pharyngeal erythema

Neck: soft, no tenderness, no masses

Chest: clear to auscultation bilaterally, no dullness, no hyper-resonance

Abdomen: flat, no masses, no scars, no hepatomegaly, no splenomegaly, normal tympanic note percussion, 2 bowel sounds heard in one minute.

Extremities: normal bulk, power, and tone in muscle groups in both upper and lower limbs. The left fifth finger has a swan-neck appearance, and no bleeding or discharge is observed. The distal interphalangeal joint is swollen, with no erythema, limited passive extension, limited passive flexion, and no distal cyanosis. The finger’s temperature is normal. Tenderness was observed on active flexion and extension. The other fingers are normal. The patient cannot make a fist satisfactorily due to the deformity in the left little finger.

Diagnostic results: x-ray of the hand taken in the emergency room showed no abnormal findings, and no fractures or deformities were reported.

A.

Differential Diagnoses

  1. Mallet finger: Mallet’s finger occurs after an injury to the finger, most commonly from forced flexion of the distal interphalangeal (DIP) joint (Khera et al., 2021). This patient most likely had a mallet finger because the only joint involved was the DIP of the left little finger. He could not extend the tip of his finger and has a possible source of trauma from his cabinet. Mallet finger can be painful or painless as exhibited by the finger. Swan neck deformity may develop when this injury is not treated over time.
  2. Boutonniere/ Buttonhole deformity: This deformity represents a disruption of the central tendon, resulting in its slip at the proximal interphalangeal joint (PIP) (Elzinga & Chung, 2019). The fixed appearance of this patient’s finger suggested a buttonhole deformity because of the flexion. However, the location of the deformity makes buttonhole deformity unlikely. Buttonhole deformities can cause aesthetic concerns to patients, resulting in similar office visits. Fortunately, these patients can make fists, thus preserving the functionality of the finger
  3. Interphalangeal dislocation of the distal interphalangeal joint: interphalangeal dislocations are also common and could be possible for this patient. These dislocations are usually painful and also result from hyperextension of the distal interphalangeal joint, when the central ligaments resist this excessive force, resulting in the displacement of the joint bones (Sem et al., 2019). Diffuse pain, swelling, and tingling are common presentations of these dislocations. This patient didn’t report tingling or significant pain, thus making this differential less likely.

This patient would not benefit from further imaging of his hand being that both lateral and postero-anterior x-ray radiographs had been done. His management will include continuing the splinting and analgesia. This patient will take Advil, 200mg PO q6hr daily for the next five days. Splitting and immobilization of the affected finger will promote healing in a straight fashion (Khera et al., 2021). The patient will come again to the office for reassessment to check if the finger is healing in a straight manner. Weaning of the full-time splinting will start after 2 weeks with two-fortnight reassessments.

Reflections

This patient came to the office because the earlier management strategies could not return his finger to the pre-injury state. Despite adequate pain management, the patient still sought care. Usually, pain becomes the primary reason for seeking care for such injuries, but that was not the case. However, this patient would require this further analgesia because the full-time splinting will cause some discomfort and pain. He also understood other alternative treatments such as different splinting such as open reduction and fixation and no treatment. Ethically, this patient was explained to the risks and benefits of splinting in his case vis-a-vis surgery. He expressed understanding of complications and concerns with surgery and no treatment. Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

Elzinga, K., & Chung, K. C. (2019). Managing swan neck and boutonniere deformities. Clinics in Plastic Surgery, 46(3), 329–337. https://doi.org/10.1016/j.cps.2019.02.006

Khera, B., Chang, C., & Bhat, W. (2021). An overview of mallet finger injuries. Acta Bio-Medica: Atenei Parmensis, 92(5), e2021246. https://doi.org/10.23750/abm.v92i5.11731

Sem, S. H., Omar, M. F., & Muhammad Nawawi, R. F. (2019). Irreducible dorsal distal interphalangeal joint dislocation of finger: A case report and perspectives on management. Cureus, 11(5), e4588. https://doi.org/10.7759/cureus.4588

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To prepare:

Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.

Select a patient you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following on a Focused Note:

Assignment:

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, follow-up parameters, and a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation?

Patient Information: J.D. 18, Male, Hispanic

Subjective:

CC: “ my left pinky has gone crooked”

Case background: pt was going through his file cabinet the night before when he felt a “tug” at his left fifth digit. As he got his hand out of the cabinet, he noticed the tip of the finger bent and beginning to swell. Went to ER, but no fx per x-ray. The finger was placed on a splint and was advised to ff up at the primary physician’s clinic for a referral/ consult to a hand trauma surgeon for a mallet finger dx.

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