[doctor] hi , ms. brooks . i'm dr. baker . how are you ?
[patient] hi , dr. baker .
[doctor] is your , is your right finger hurting ?
[patient] yes .
[doctor] okay . hey , Sarah , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened .
[patient] well , i was skiing over the weekend-
[doctor] okay .
[patient] . and as i was , um , coming down the hill , i tried moguls , which jumping over those big hills , i tend to get my strap caught on my finger-
[doctor]
[patient] . and it kind of bent it back a bit .
[doctor] okay .
[patient] yeah .
[doctor] and when did this happen ?
[patient] it happened , uh ... that was sunday .
[doctor] okay . and have you tried anything for this or anything made it better or worse ?
[patient] i tried , um , putting ice on it .
[doctor] okay .
[patient] uh , and then i- i've been taking ibuprofen , but it's still very painful .
[doctor] okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh-
[patient] yeah , movement .
[doctor] okay .
[patient] yes .
[doctor] okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ?
[patient] um , i have been suffering from constipation recently .
[doctor] okay . all right . and do you take ... what medicines do you take for constipation ?
[patient] um , i've just been taking , um , mel- um ...
[doctor] miralax ?
[patient] miralax . that's it .
[doctor] okay . miralax is sufficient .
[patient] miralax . yes .
[doctor] and any surgeries in the past ?
[patient] i did have my appendix taken out when i was 18 .
[doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ?
[patient] no .
[doctor] okay . and how'bout right there ? no ?
[patient] no .
[doctor] right here ?
[patient] that hurts .
[doctor] all right . uh , can you bend your finger for me ?
[patient] yeah .
[doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ?
[patient] yes .
[doctor] all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pain flexion as well . so , let's look at your x-rays . hey , Sarah , show me the x-rays .
[doctor] all right . so , on this x-ray.
everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ?
[patient] okay .
[doctor] okay . do you have any questions ?
[patient] no . i think that sounds good .
[doctor] okay . hey , Sarah , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out .
[patient] okay . thank you .
[doctor] all right . finalize report , Sarah .
CC:

Right finger pain.

HPI:

Ms. Brooks is a 48-year-old female who presents today for an evaluation of right finger pain. She states she was skiing on Sunday and hyperextended her finger when it became caught in a strap on a jump. She has tried applying ice and taking Ibuprofen, but it is still very painful. She has pain with movement.

CURRENT MEDICATIONS:

MiraLax

PAST MEDICAL HISTORY:

Constipation.

PAST SURGICAL HISTORY:

Appendectomy.

EXAM

Examination of the right index finger shows tenderness over the distal phalanx. No tenderness over the proximal phalanx or the MP joint. Pain with flexion.

RESULTS

X-rays of the right hand show no obvious signs of fracture or bony abnormalities.

IMPRESSION

Right hand index finger contusion at the tip of the finger.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.
