IME-QME-Work Comp etc.
Sample Name: Worker's Compensation Injury
Description: Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Worker’s compensation injury.
HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well, but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talking about. The patient seems to understand our conversation fairly well. She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m. She was pushing a cart and mashed her thumb between the cart and the wall. This was at the finishing room in Norcraft. She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th. She has swelling in her thumb. It hurt only if it is pushed on. It was the distal end of her thumb that was mashed. She has not noticed any numbness or tingling or weakness. She has not sought any treatment for this, is not taking any pain medications. She did try soaking it in warm salt water and did not notice any improvement.
PAST MEDICAL HISTORY: Possible history of chicken pox, otherwise no other medical illnesses. She has never had any surgery.
SOCIAL HISTORY: The patient is single. She lives with her boyfriend and his father. She works at Norcraft. She wears seatbelt 30% of the time. I encouraged her to use them all of the time. She is a nonsmoker, nondrinker.
VACCINATIONS: She thinks she got a tetanus vaccine in childhood, but does not know for sure. She does not think she has had a tetanus booster recently.
REVIEW OF SYSTEMS:
Constitutional: No fevers, chills, or sweats.
Neurologic: She has had no numbness, tingling, or weakness.
Musculoskeletal: As above in HPI. No other difficulties.
General: This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.
Vital Signs: Weight: 121.4. Blood pressure: 106/78. Pulse: 64. Respirations: 20. Temperature: 96.
Extremities: Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed. The nail bed is pushed up. I can see hematoma below the nail bed, although it does appear to be intact. She has some blue fingernail polish on her nail also, but that is starting to come off. She is able to bend her thumb normally at the DIP joint. She has no discomfort doing that. Sensation is intact over the entire thumb. She has normal capillary refill. There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed. I am not feeling any fluctuance. I do not think it is a collection of pus. There is no drainage. She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all. It looks like there may be some mild cellulitis at the site of her injury.
LABORATORY: X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.
ASSESSMENT: Blunt trauma to the distal right thumb without fracture. I think there is some mild cellulitis developing there.
1. We will give a tetanus diphtheria booster.
2. We will start Keflex 500 mg one p.o. q.i.d. x 7 days. I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb. I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time. If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call. Otherwise I will be seeing her back on Monday.
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