Chapter 4: The Musculoskeletal System | Ezilary Morales' Chart Note

CHART NOTE

Patient Name: Morales, Ezilary
ID Number: 93668
Examination Date: March 14, 20xx

SUBJECTIVE
This 15-year-old female suffered an injury to her left hand during a gymnastics tournament. She was splinted and sent to the office for evaluation.

OBJECTIVE
She has diffuse (spread out; scattered) edema and ecchymosis over the dorsal aspect of her left hand in the 3rd and 4th metacarpal region. She has full range of motion of her fingers. Neurological and sensory exam is normal. Peripheral circulation (blood flow to the upper and lower extremities) is normal. X-ray imaging shows evidence of a nondisplaced oblique (slanted) shaft fracture of the metacarpals without involvement of the joints.

ASSESSMENT
Right 3rd and 4th metacarpal fractures, nondisplaced.

PLAN
Her fingers were taped for immobilization and placed in a short-arm splint. She will keep it elevated and use Advil® for pain relief. She is scheduled for a follow-up visit with Orthopedic Specialists, Inc. in the next 3 to 7 weeks.