Wrist pain

Patient: Michael Turner

Age: 78

Place of Service: Office – Outpatient

Patient Status: New Patient

Chief Complaint: Right wrist pain following a fall.

History of Present Illness (HPI):

The patient is a 78-year-old male presenting to the office for evaluation of right wrist pain following a mechanical fall earlier today. Due to baseline moderate dementia, the patient is unable to provide a complete and reliable history.

History was obtained from the patient’s daughter, who accompanied him to the visit, and from review of available records. Per the daughter’s report, the patient tripped at home while ambulating without his walker and fell onto his outstretched right hand. There was no reported head injury, loss of consciousness, seizure-like activity, or post-fall confusion.

Since the fall, the patient has complained of right wrist pain and has been guarding the extremity. There is no report of numbness, tingling, or prior injury to the right wrist.

Review of Systems (ROS):

• Musculoskeletal: Right wrist pain
• Neurologic: No loss of consciousness reported
• Skin: No open wounds or bruising
• All other systems reviewed and negative per independent historian

Past Medical History:

• Dementia
• Hypertension

Medications:

• Lisinopril
• Donepezil

Allergies: No known drug allergies

Physical Examination:

• General: Alert, cooperative, cognitively impaired
• Right Wrist: Mild swelling and tenderness; no deformity; limited ROM due to pain
• Neurovascular: Sensation intact; capillary refill normal
• Skin: Intact

Diagnostic Data:

• Right wrist X-ray ordered and reviewed – no acute fracture or dislocation

Assessment:

Acute right wrist sprain following mechanical fall.

Plan:

• Findings discussed with the patient’s daughter
• Wrist splint applied
• Acetaminophen as needed for pain
• Physical Therapy and Occupational Therapy referrals placed
• Fall precautions reviewed