Chief Complaint & History of Present Illness :
18yo F with R index finger avulsion injury sustained 08/30/2019 when opening a connector door on a train. TDAP UTD. Patient reports she performed basic wound care 08/30/2019. Moves without issue. Patient complains of mild pain. Patient requesting further evaluation.
Past Medical History :
PMH: mitochondrial disease
Social History
freshman at UC Merced, parents at bedside
Review Of Systems
ROS: All systems reviewed and found to be negative except those mentioned in the history of present illness.
Vital Signs
Most Recent Set of Vitals:
BP: 126/85 08/31/ 12:38
Pulse: 78 08/31/ 12:38
Temp: 37.2 C 08/31/ 12:38
Resp: 16 08/31/ 12:38
02 Sat: 99%(Room Air) 08/31/ 12:38
Calculated BMI: 19.6 08/31/ 12:38
Physical Exam
General: Awake, alert, oriented x3, cooperative, and in no apparent distress.
Head: Normocephalic and atraumatic.
Eyes: Pupils equal and reactive to light, extraocular movements intact, sclera anicteric.
ENT: Airway patent and protected.
Neck: No meningeal signs
Respiratory: Clear to auscultation bilaterally, no respiratory distress.
Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops.
Musculoskeletal: Extremities atraumatic, ROM intact. Peripheral pulses intact throughout and symmetric.
Neurologic: Moves all extremities normally, speech and coordination normal.
Skin: 1 cm superficial avulsion injury to the palmar aspect of right 2nd digit. No erythema or purulent drainage. No acute appearing lesions or rashes noted.
Medical Decision Making (MDM) :
18-year-old female with hx of mitochondrial disease, with superficial avulsion injury to the right 2nd digit sustained 08/30 while on a train. No repair necessary. Wound was irrigated by ER technician under my supervision and wound care provided. Advised patient on continued wound care and signs of infection to be aware of, especially given immunocompromised state. Patient to follow up with primary care in 3-5 days if wound not healing appropriately. ER return precautions reviewed.Patient and parents verbalized understanding of plan.
ED Diagnosis (Current Problem List) :
Assessment and Planning:
Avulsion of skin None Associated Active
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
Condition at D/C: stable
99282
Emergency department visit for the E/M of pt, requires these 3 key components: Expanded problem focused hx; Expanded problem focused exam; Medical decision making of low complexity. Counseling &/or coordination of care with other physicians, other QHCPs, or agencies consistent with the nature of the problem(s) & the patient’s &/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity
S61.200A Unspecified open wound of right index finger without damage to nail, initial encounter
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