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Patient: JW
Sex: Male
Ethnicity: African American
Primary language: English
Age: 29
Marital status: single
Address: Bronx, NY
Date: 2/14/23
Time: 11:30 AM
Location: Metropolitan ED
Self, reliable
CHIEF COMPLAINT
“I have increasing pain in my right hand from frostbite 2 weeks ago” x 1 day
HPI
29 yr old male with no PMH presented to the ED complaining of increased pain and signs of frostbite to his right hand x1 day. He says that 2 weeks ago he was working at night in <10 degree weather pushing a delivery handcart with a metal handle with thin gloves on. After 6 hours out in the cold, he was experiencing coldness and numbness in his right hand which prompted him to seek care at Mt. Sinai St. Lukes ER. At that time he did not notice any significant overlying skin changes. Per patient, he received a tetanus shot and they rewarmed his right hand. Since yesterday his pain has gotten progressively worse and he is experiencing increased numbness and decreased ROM as well as worsening blistering and skin discoloration. He denies any fever, chills, headache, dizziness, shortness of breath, cough, chest pain, abdominal pain, N/V/D or urinary symptoms.
Denies past medical history
Denies past surgical history
Denies taking any medications or supplements
ALLERGIES: NKDA
Peanuts: reaction hives
No known family history
SOCIAL HISTORY: Admits to smoking 3 cigarettes per day, using alcohol on occasion, and denies drug use
General: Denies loss of appetite, fatigue, fever or chills
Skin, hair, and nails: admits to discolorations and blistering on right hand digits 2-5, denies dryness or sweating, pruritus
Head: Denies headache, vertigo
Eyes: Denies vision problems, dryness, tearing
Ears: Denies trouble hearing, ear pain
Nose/Sinuses: Denies discharge, epistaxis, obstruction
Mouth and throat: Denies sore throat, mouth ulcers
Neck: Denies neck pain, stiffness
Lungs: Denies shortness of breath, cough, hemoptysis
Cardiovascular: Denies Irregular heartbeat, palpitations, chest pain, syncope, leg swelling
Gastrointestinal System: Denies constipation, N/V/D, abdominal pain
Genitourinary System: Denies dysuria, frequency, urgency, hematuria
Nervous System: Denies headache, dizziness
Musculoskeletal System: Admits to pain, altered sensation and decreased range of motion to the right distal extremity
Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance
Psychiatric: Denies depression/sadness
VITALS:
Height: 72 inches
Weight: 150 lbs
BMI: 20.34
Blood pressure: 131/80 right arm sitting
Temperature: 98.6 F
Pulse: 74 bpm regular
Respirations: 18 breaths per minute
O2 saturation: 97% on RA
General: Pt is sitting in a chair, A and O x3, afebrile, in no acute distress, well developed, hydrated, Appears stated age.
Skin and extremities: right hand with dark discolorations to digits 2-5. Large blisters with serous fluid. Active drainage on the 3rd digit. Palmar aspect with dark discolorations. No evidence of tight compartments. Capillary refill 2-3 seconds in all digits. Radial pulses are +2 bilaterally.
Tenderness to palpation in affected digits on right hand, altered sensation to light touch, sensation to pressure intact. Strength and range of motion of right hand limited by pain.
Left hand without skin changes, pain, altered sensation. Strength 5/5, full ROM.
HEENT: The head is normocephalic and atraumatic, no visible masses, depressions, or scarring. Hair is normal and evenly distributed.Conjunctivae are clear. Sclera is non-icteric. Eyelids are normal in appearance. Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions. The pharynx is normal in appearance without tonsillar swelling or exudates.
Neck: The neck is supple without adenopathy. Trachea is midline.
Cardiac: Heart rate and rhythm are regular, pulses +2. S1 and S2 are heard and are of normal intensity. No murmurs, gallops, or rubs. No lifts, heaves, or thrills.
Respiratory: Lungs are clear with symmetrical expansion. Normal work of breathing, No signs of respiratory distress.
Abdominal: Abdomen is soft, symmetric, and non-tender, no rebound, no guarding. Bowel sounds are present and normoactive in all four quadrants. No masses noted.
Neurological: The patient is awake, alert, and oriented to person, place and situation, with normal speech.
Psychiatric: Pt is in no emotional distress.
LAB VALUES:
- CBC: WBC 7.6, HGB 14.5, HCT 42.7, PLT 231
- BMP: sodium 138, potassium 4.0, chloride 104, CO2 28, BUN 24, Cr .8, glucose 96
ASSESSMENT AND PLAN:
29 year old male with no PMH presents with signs of second degree frostbite to his right hand x2 weeks with no evidence of acute infection. He has severe pain in right digits 2-5 and altered sensation. Hand surgery consult placed who recommended surgical debridement.
# frostbite with severe pain in right hand
- bacitracin to open wound in ED
- IM Toradol 30 mg
- Disposition: admission to med/surge for debridement, peroxide and betadine soak
