DIALOGUE

[doctor] hey , ms. hill . nice to see you .
[patient] hi , dr. james , good to see you .
[doctor] hey , dragon , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ?
[patient] um , i am having a lot of pain at the end of my right middle finger .
[doctor] what did you do ?
[patient] a little embarrassing . um , i got rear-ended , slow motor , uh , vehicle accident , and i got really angry with the person who hit me , so i went to flip him the bird , but i was a little too enthusiastic .
[patient] and i hit the ceiling of the car .
[doctor] okay . when did this happen ?
[patient] uh , it was saturday , so about four , five days ago .
[doctor] five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ?
[patient] yes . so i was stopped at a four-way stop , and it was not my turn to go . there were other cars going , and the person behind me just was n't watching . i think they were texting and rear-ended me .
[doctor] how much damage to your car ?
[patient] uh , not too much . the , the trunk crumpled up a little bit .
[doctor] okay . and no other injuries ? just the finger ?
[patient] just the middle finger .
[doctor] so you would've escaped this accident without any injuries ?
[patient] yes . uh , i'm not proud .
[doctor] okay . um , so four days of right middle finger pain-
[patient] yes .
[doctor] . after a motor vehicle accident .
[patient] yes .
[doctor] all right . um , let's look at your x-ray . hey , dragon , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ...
[patient] great .
[doctor] very interesting . let me check it out . um , so does it hurt when i push right here ?
[patient] yes .
[doctor] and does that hurt ?
[patient] very much so .
[doctor] what about down here ?
[patient] no .
[doctor] okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those .
[patient] okay .
[doctor] and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ?
[patient] yes . so i'm taking digoxin for afib . will the tramadol be okay with that ?
[doctor] it will be okay . so you have atrial fibrillation .
[patient] yes .
[doctor] you take digoxin .
all right . any other questions for me ?
[patient] no , that's it . thank you .
[doctor] you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .

CLINICAL NOTE

CC:

Right middle finger pain.

HPI:

Ms. Hill is a 41-year-old female who presents today for an evaluation of right middle finger pain after she was rear-ended in a motor vehicle accident. She has no other injuries.

CURRENT MEDICATIONS:

Digoxin

PAST MEDICAL HISTORY:

Atrial Fibrillation

EXAM

Examination of the right middle finger shows tenderness over the distal phalanx.

RESULTS

X-rays of the right middle finger, 3 views obtained on today's visit shows a comminuted distal phalanx fracture.

IMPRESSION

Right middle finger distal phalanx fracture.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I recommend a prescription for Tramadol 50 mg every 6 hours as needed for pain, dispense 8. She is provided a finger splint and will return in 2 weeks for a follow-up x-ray. All questions were answered.