OrthopedicsHuzaifa Hamid Ahmad

Personal information:

Name: Sabah Muhammad Salh

Age: 41

Gender: male

Occupation: Butcher

Address: Sayd Sadq

Date of admission: 14/4/2015

Date of Examination: 14/4/2015

Chief complaint

Right ring finger pain for 3 hours duration

History of present illness

The condition started suddenly when the patient

was trying to slaughter a cow. He suddenly hit his

right ring finger distally with a knife, the finger was

cut off and separated completely. There was

bleeding at the site of the injury. the bleeding

was not severe because he pressed on it and

stopped the bleeding. There was severe

continues pain. Not radiating to any where, no

aggravating or relieving factor. He couldn’t

move his finger. There was mild degree of fever.

He came to emergency department and

admitted there. They cleaned the injury and

dressed it and then analgesics were given.

Investigations like X-Ray, CBC, viral markers and

ECG done, the doctor decided to do an urgent

surgery for him.

The X-Ray showed the distal phalanx fracture.

Other investigations were all normal.

Review of systems:

Gastrointestinal: -ve

Respiratory: -ve

Cardivascular: -ve

Genito-urinary: -ve

Central nervous system: -ve

Musculoskeletal: mentioned

Past medical history:

No DM, no HTN no asthma.

No previous admission.

Previous injury: no

Drug history:

No known drug allergies.

Not on any chronic medication.

Past surgical:

Negative.

No any blood transfusion.

Family history:

No HTN, No DM

Social history:

No passive smoker

Own house

Three family member

Tap water

animal contact

Examination:

Vital sign:

BP: 130/85

RR: 15

PR: 88

Temp: 37.3

Physical examination:

A young aged male sitting on his bed, conscious, alert,

cooperative, there was no dyspnea, no cyanosis, no pallor,

no jaundice, no palpable lymph nodes. No clubbing, no

bilateral pitting leg edema.

Look: no any congenital anomaly of the hands, no

swelling of the affected hand, no erythema. There was

dressing over the right ring finger no any bleeding.

Feel: No any temp. change, the right proximal ring

finger was tender, no crepitus, the pulses of the right and

left hand was palpable and normal, no tenderness of the

hands.

Move: Normal movement of the right hand, no any

limitation of movement apart from ring finger. On the left

hand, no any limitation of movement.

Neurological examination:

Normal tone, power, reflex of the upper limb, Normal

sensory.

Apart from ring finger which was tender and neurological

examination couldn’t be done.