Emergency Department Visit

Patient Name: Rachel T.

Date of Birth: [Redacted]

Age: 31

Sex: Female

Date of Visit: [Approx. 3–4 months prior to current visit]

Location: Emergency Department

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Chief Complaint

Left-sided chest pain after a fall.

History of Present Illness

Patient is a 31-year-old female who presents with left-sided rib pain following a reported fall down a flight of stairs at home two days prior to arrival. Patient reports immediate pain to the left chest wall, worsened with deep inspiration, coughing, and movement. Denies loss of consciousness. Denies shortness of breath at rest. Pain rated 7/10.

Patient’s description of the fall was vague. She reports she “missed a step” but is unable to clearly describe how she landed. She delayed seeking care due to believing the pain would improve on its own.

Past Medical History

• Migraines

Past Surgical History

• None reported

Medications

• Ibuprofen as needed for pain

Allergies

• No known drug allergies

Social History

• Lives with partner
• Denies tobacco use
• Denies illicit drug use
• Occasional alcohol use

Review of Systems

• Positive for chest wall pain
• Negative for shortness of breath, palpitations, fever
• Reports difficulty sleeping due to pain

Physical Examination

• General: Anxious appearing female, uncomfortable but cooperative
• Chest: Tenderness to palpation over left posterior ribs, mild bruising noted along left lateral thorax
• Respiratory: Breath sounds clear bilaterally, no respiratory distress
• Cardiovascular: Regular rate and rhythm

Imaging

• Chest X-ray: Posterior fracture of left 7th and 8th ribs without displacement. No pneumothorax.

Assessment

• Left posterior rib fractures
• Chest wall contusion

Plan

• Pain control with acetaminophen and limited NSAID use
• Incentive spirometry encouraged
• Activity modification
• Return precautions discussed (worsening pain, shortness of breath, fever)

Disposition

Discharged home in stable condition.

Provider Notes

Patient appeared anxious throughout the visit. Mechanism of injury somewhat unclear. Injury pattern noted. Patient declined social work consult when briefly offered and stated she felt safe returning home.

Emergency Department / Urgent Care Visit

Patient Name: Rachel T.

Date of Birth: [Redacted]

Age: 30

Sex: Female

Date of Visit: [Approx. 12–14 months prior to current visit]

Location: Emergency Department / Urgent Care

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Chief Complaint

Right index finger pain and swelling after injury.

History of Present Illness

Rachel T. is a 30-year-old female who presents with pain, swelling, and limited movement of her right pointer (index) finger following an injury that occurred earlier in the day. The patient reports that her finger was injured at home but provides limited details about the mechanism, stating only that it was “bent the wrong way.”

Pain is localized to the proximal portion of the index finger and is described as sharp and aching, rated 5–6/10. Pain is worsened with movement or attempts to grip objects. Patient delayed seeking care, hoping the pain would improve on its own.

Past Medical History

• Migraines

Past Surgical History

• None reported

Medications

• Ibuprofen as needed

Allergies

• No known drug allergies

Social History

• Lives with partner
• Right-hand dominant
• Denies tobacco and illicit drug use
• Occasional alcohol use

Review of Systems

• Positive for finger pain, swelling, and stiffness
• Negative for numbness or tingling
• No other injuries reported

Physical Examination

• General: Alert, anxious appearing female, cooperative but guarded
• Right Hand / Index Finger:
  • Swelling and tenderness over the proximal phalanx of the index finger
  • Mild bruising noted
  • Decreased range of motion secondary to pain
  • No open wounds or deformity
  • Sensation intact, capillary refill < 2 seconds

Imaging

• X-ray of right hand:
  • Fracture of the proximal phalanx of the index finger with mild displacement
  • No intra-articular extension
  • No additional fractures identified

Assessment

• Closed fracture of the proximal phalanx of the right index finger

Plan

• Finger splint applied for immobilization
• Pain control with acetaminophen; advised limited NSAID use
• Ice and elevation recommended
• Orthopedic or hand specialist follow-up advised within 7–10 days
• Return precautions reviewed (increasing pain, numbness, discoloration)

Disposition

Discharged home in stable condition.

Provider Notes

Patient was hesitant when asked to describe the mechanism of injury and provided minimal detail. Injury pattern documented. Patient declined further discussion and expressed desire to return home promptly.