CHIEF COMPLAINT: Sliver glass puncture wound to the right middle finger.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department complaining of workplace injury that she suffered earlier today when she accidentally punctured her right middle finger fat pad with a sliver from a clean broken glass vial that she was picking up off the floor. She indicates no possible blood exposure as this was a clean glass vial that she apparently broke when she dropped it on the floor. She presents now for evaluation and treatment of the same.
PAST MEDICAL HISTORY: COPD, coronary artery disease, and esophageal reflux.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: Coreg, Prilosec, aspirin, potassium, and Combivent.
ALLERGIES: NSAIDs.
IMMUNIZATION HISTORY: Specifically, tetanus is up-to-date.
SOCIAL HISTORY: The patient is a nonsmoker and denies substance or alcohol abuse.
REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting or diarrhea. She denies any bone, tendon or ligament involvement with this injury, as well as any sensation of retained foreign material or localized evidence of infection at the wound site. She denies any limited range of motion of the digit, numbness, tingling or paresthesias to the same. Remainder of her review of systems otherwise negative as pertains to chief complaint.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature not obtained, pulse 78, respirations 20, blood pressure 132/66, and pulse oximetry 94% on room air.
GENERAL: The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old Hispanic female.
MUSCULOSKELETAL: Focused musculoskeletal examination reveals a very superficial puncture wound to the volar fat pad of the third digit of the right hand. There is no evidence of fluctuance, purulent drainage, vascular streaking or evidence of retained foreign material at the wound site. Bleeding has stopped. She exhibits full range of motion of the right wrist, hand, and digits without deficit. She exhibits strong distal radius pulse, brisk capillary refill in all digits of the right hand.
NEUROLOGIC: Without gross motor or sensory deficits. The patient is alert, cooperative, and exhibits intact distal sensation in all digits of the right hand.
INTEGUMENTARY: Examination without diaphoresis, rash, lesions with the exception of a puncture wound as noted above. Skin is otherwise warm and dry to touch and normal tone and turgor.
DIAGNOSTIC DATA: None.
EMERGENCY DEPARTMENT COURSE: Bacitracin ointment and a Band-Aid applied to the affected area prior to the patient’s discharge. She has otherwise been stable throughout her stay in the emergency department.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. Jane Doe, who also evaluated the patient. She agreed with the final diagnosis of right middle finger glass puncture wound and treatment plan that follows.
PROCEDURES: None.
CONSULTATIONS: None.
IMPRESSION: Right middle finger glass puncture wound.
PLAN:
1. Care instructions are given to the patient.
2. Return to the emergency department if any signs of infection arise or for new concerns.
