CHIEF COMPLAINT: Left fourth toe injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who has had a recent patellofemoral syndrome diagnosed by Orthopedic Surgery with a patellofemoral tendon release performed several days ago. She is on crutches for this per Orthopedic Surgery. She was walking at home today on her crutches, stumbled, and hit her left fourth toe with her crutches and thinks she may have broken it. She now has an 8/10 pain in the left toe radiating to the left foot, worse with walking, better after taking Vicodin, sharp and tight in nature. No other injuries were sustained. The patient has no other complaints today.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Patellofemoral syndrome as above.
MEDICATIONS: Vicodin for patellofemoral syndrome.
ALLERGIES: None.
SOCIAL HISTORY: The patient denies tobacco, alcohol or drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As in the HPI. All systems reviewed and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 148/98, pulse 54, respirations 18, temperature 97.8, and saturations 98% on room air.
GENERAL: This is a very pleasant Hispanic female who is in no acute distress.
MUSCULOSKELETAL: The patient has evidence of a slightly ecchymotic, swollen right fourth toe with tenderness to palpation, both on the dorsal and the volar aspect and at the metatarsal head. No associated neurologic deficits are noted. Cap refill is less than 4 seconds. She has strong palpable dorsalis pedis and posterior tibial pulses on that side. The remainder of the musculoskeletal exam was within normal limits with the exception of an Ace bandage around her right knee due to her recent patellofemoral syndrome surgery.
NEUROLOGIC: Nonfocal.
EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated. X-ray was obtained showing a fracture of the middle phalanx of the fourth toe. At this point, we did not elect to tape it to the neighboring toe, as it is acutely swollen and this will cause her more pain. She is advised that she may do this at home to help with proper healing process. She was given Motrin 800 mg here for pain, and due to her already limited weightbearing status on the right due to recent orthopedic surgery and now with her toe fracture on the left, we have prescribed her a walker to help with ambulation. She is subsequently discharged home.
MEDICAL DECISION MAKING: This is a (XX)-year-old Hispanic female with isolated trauma to the left fourth toe with obvious middle phalanx fracture. She may splint this at home once the swelling goes down. She is instructed to rest, ice and elevate, to ambulate using the assistance of a walker. This should heal well over time. This is a noncomminuted fracture. It does not involve the metatarsals themselves, only the middle phalanx. She is following with Orthopedic Surgery already this Wednesday, and she may have that reevaluated there if it is not improving.
DIAGNOSIS: Left fourth toe fracture.
DISPOSITION: To home in good condition.
PLAN: As above.
1. Return in the interim for worsening symptoms.
2. She is given Naprosyn 500 mg p.o. b.i.d., #30, for pain.
3. She has Vicodin at home, which she can take for breakthrough pain and also given prescription for a walker.
