CHIEF COMPLAINT: Thumb laceration.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who comes to the emergency department with a complaint of a thumb laceration. This was on a rock. He was laying some rock out front of his house when a hatchet bounced off the rock and hit his thumb. He does not think his thumb is broken. He is able to move it without difficulty. He says the pain is really mild. He is able to feel everything. He has had plenty of stitches before. He states this is nothing new to him. He says he feels fine, just needs a few stitches. Nursing notes reviewed.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
CURRENT MEDICATIONS:
1. Naprosyn.
2. Lyrica.
IMMUNIZATIONS: Unknown.
SOCIAL HISTORY: The patient does not use tobacco products.
REVIEW OF SYSTEMS: The patient denies any weakness, numbness or tingling. Review of systems is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 72, respirations 18, blood pressure 146/92, pulse 96%.
GENERAL: A well-appearing, nontoxic (XX)-year-old male. He is alert. He is oriented x3. He is calm and cooperative throughout the exam.
EXTREMITIES: Over the left thumb, over the radial aspect, there is a flap-like laceration. This does start to encompass the radial aspect of the nail. On further investigation, there is just a crack of the nail bed. It does not appear that there is a subungual hematoma. It does not appear we need to take off his nail. He is able to flex and extend the interphalangeal joint without difficulty. He has good sensation distally. He has good radial pulse at 2+.
DIAGNOSTICS: Three-view x-ray was taken of the left thumb and read as no fracture, no dislocation, foreign body.
PROCEDURE: The area was infiltrated with a digital block, 5 mL bupivacaine without epinephrine with good results. The area was scrubbed with Shur-Clens, 210 mL of normal saline under pressure. The wound was draped in the normal sterile fashion. The wound was explored, no foreign body seen or palpated. No tendon or joint involvement seen. This is a flap-like laceration. There is no bony tissue involvement. The area was closed using a total of 5 simple interrupted sutures with good wound approximation. PSO ointment was placed and a sterile bandage was applied.
EMERGENCY DEPARTMENT COURSE: Given a tetanus shot here.
MEDICAL DECISION MAKING: The patient is well appearing. There are no foreign bodies seen or palpated. He has good flexion, extension. There are no signs of decreased sensation. He is to follow up with his family physician in 7 to 10 days.
IMPRESSION: Left thumb laceration, 3 cm.
DISCHARGE INSTRUCTIONS:
1. Follow up with primary care physician in 7 to 10 days for suture removal.
2. Return for pain, redness or swelling.
3. Wound care.
