Index Finger Injury Chart Note Sample

DATE OF SERVICE: MM/DD/YYYY

CHIEF COMPLAINT: Right index finger injury from a week ago.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male who injured his right index finger almost a week ago when he cut it while using a pocket knife. The pocket knife evidently buckled, cutting the dorsum of his right index DIP joint. He was aware that the digit dropped in flexion at the DIP joint, and he was unable to extend this.

The patient was evaluated at an outside hospital where his wound was sutured. He was referred to this facility for followup care of a tendon injury. The patient is accompanied by his wife on this visit today. He reports minimal discomfort associated with the injury. He denies numbness or tingling of the digit, however.

PAST MEDICAL HISTORY: Pertinent for asthma and hypertension.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Atenolol, diazepam, and fluticasone.

ALLERGIES: Multiple medication allergies, listed in the chart.

SOCIAL HISTORY: This is a (XX)-year-old married male who lives with his wife and one child. The patient smokes a pack of cigarettes daily. He denies drug and alcohol use.

REVIEW OF SYSTEMS: The patient denies any cardiorespiratory symptoms, including chest pain, palpitations, shortness of breath, wheezing, coughing, fever, chills or malaise.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-appearing (XX)-year-old male who is alert and oriented, in no acute distress.
HEART: Heart rate of 60 with a regular rate and rhythm without murmur, rub or gallop.
LUNGS: Clear to auscultation.
EXTREMITIES: Focused examination of the right index finger demonstrates a 1 cm transverse wound across the dorsal DIP joint. The wound has almost completely healed. There are three residual nylon sutures, which are all removed today. There is no localized erythema, induration, swelling or tenderness. There is an extensor lag of approximately 20 degrees at the DIP joint. There is full passive extension of the distal phalanx at the joint. There is mild hyperextension at the PIP joint.

IMPRESSION AND PLAN: This is a (XX)-year-old right-hand dominant male, now almost one week out from a laceration to the dorsal right index finger with injury to the terminal extensor tendon.

All of this was discussed today with the patient. The case was reviewed today with Dr. John Doe who recommends closed reduction, percutaneous pinning, and repair of the terminal extensor tendon. The patient is agreeable to having this done.

The potential risks and complications associated with the procedure were reviewed and discussed today with the patient. He was cautioned that due to the unstable nature of the tendon in this area that repair is very difficult and sometimes not completely successful, and that he may, as a result of this injury, end up with a mild permanent flexion at the DIP joint. He was cautioned that the pin will need to remain in place for upwards of six to eight weeks and that he will be required to work on hand therapy upon pin removal.

The patient verbalized understanding and acceptance of all of this. Informed consent was obtained. The patient was re-placed today into a radial gutter splint. Arrangements will be made to have this done next week.

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