[doctor] hello , mrs . martinez . good to see you today .
[patient] hey , dr . gomez .
[doctor] hey , Sarah , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ?
[patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm .
[doctor] so you have pain in your distal radius ?
[patient] yes .
[doctor] how did that happen ?
[patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm .
[doctor] okay . and did it swell up at all ? or-
[patient] it did . it got a ... it had a little bit of swelling . not a lot .
[doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ?
[patient] a little bit when i move my wrist . um , no numbness in my hand .
[doctor] okay . do you have any past medical history of anything ?
[patient] um , yes . allergic , um , l- i have allergies . and so i take flonase .
[doctor] okay . and any surgeries in the past ?
[patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work-
[doctor] okay .
[patient] on my rake .
[doctor] okay .
[patient] yeah .
[doctor] i was wondering where you were going to go with that .
[patient] yeah .
[doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey Sarah , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you .
[patient] okay .
[doctor] does it hurt when i press on your arm here ?
[patient] yes .
[doctor] okay . how about when i bend your arm ?
[patient] yes .
[doctor] okay . that's pretty tender , ?
[patient] mm-hmm .
[doctor] how about when i go backwards like that ?
[patient] not as much .
[doctor] and how about when i flex like this ?
[patient] a little .
[doctor] but mostly when i do that type of motion ?
[patient] yes .
[doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .
[patient] okay .
[doctor] okay , great . hey Sarah , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . Sarah you can finalize the note .
[patient] thank you .
CC:

Right arm pain.

HPI:

Ms. Martinez is a 43-year-old female who presents today for an evaluation of right arm pain after she hitting her arm on a pole while playing tennis. She had mild swelling at the time. There is pain with motion. She denies any numbness or tingling in her hand. She has a past medical history of allergies and takes Flonase.

EXAM

Examination of the left wrist shows tenderness over the distal radius and pain with flexion of the wrist and thumb.

RESULTS

X-rays of the left wrist show no obvious signs of acute fracture or other abnormality.

IMPRESSION

Right wrist sprain.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.
