History

CC:

“My L pinky finger hurts” x5 hours.

HPI:

This is a 75 year old female with PMHx of HTN and DM2 who presents to the urgent care today with complaints of pain in her L little finger for the past 5 hours. Pt says that she was walking outside this morning and tripped over an elevation in the sidewalk. She landed on her L hand. Pt denies dizziness or lightheadedness before the fall. After her fall she began to feel a sharp pain and noticed swelling, redness and bruising of her L pinky finger. She did not try anything to help alleviate the symptoms and says that movement exacerbates the pain. The pain is constant and about 7/10 in severity.    

Denies damage to the skin/nail bed, radiating pain, numbness/tingling, LOC, hitting her head, anticoagulation use and previous hand trauma.

PMHx:

• HTN
• DM2

Medications:

• Unknown meds
• Denies herbal supplement use.

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Unknown

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies past or current use
• Marital History: Married
• Language: English
• Occupational History: House wife
• Travel: No recent travel
• Home situation: Lives at home with husband, no pets. Lives around her 5 children.
• Sleep: Endorses adequate sleep and feeling well rested
• Exercise: Walks daily to do her errands
• Diet: Reports balanced diet with lean protein, vegetables and carbs.
• Caffeine: Denies caffeine use 

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Admits to swelling, redness and bruising of L little finger. Denies moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums, epistaxis, nasal congestion and sore throat.
• Neck: Denies stiffness/decreased ROM and localized swelling/lumps.
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies dyspnea, wheezing, cyanosis, cough and hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Musculoskeletal: Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, well nourished female in no apparent discomfort. Appears stated age of 75. Neatly groomed, alert and oriented x3.

Vital Signs: 

• BP:  100/73 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 70 beats per minute, regular rate, rhythm and amplitude 
• T:  98.5 degrees F (temporal)
• Height: 65 inches Weight: 135 lbs BMI: 22.5

Skin & Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted. 
• Nails: Capillary refill < 2 seconds.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. PERRLA. EOMS intact. No conjunctival injection or discharge. 
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Musculoskeletal: 

• L hand: Mild swelling and erythema of 5th finger, ecchymosis of proximal 4th and 5th finger, tender to palpation of proximal medial fifth finger, FROM of wrist and fingers with limited ROM of 5th finger due to pain. Sensations intact.

Differential diagnosis:

• Phalanx fracture
  • A phalanx fracture is a strong possibility given the mechanism of injury, where the patient landed on her left hand after tripping. The immediate onset of sharp pain, swelling, redness, and bruising in the left little finger aligns with typical signs of a fracture. Additionally, the tenderness to palpation and limited range of motion in the affected finger further support this diagnosis, as fractures often result in localized pain and difficulty moving the injured digit.
• Sprain
  • A sprain could also be considered, as it involves stretching or tearing of ligaments, which may have occurred during the fall. The swelling and bruising around the left little finger suggest that soft tissue injury is present, and the exacerbation of pain with movement supports this possibility. However, sprains typically would not cause significant swelling and bruising as prominently as seen here, which makes a fracture more likely.
• Dislocation
  • Dislocation of the finger is another potential diagnosis, as it can occur when a joint is subjected to forceful impact, such as during a fall. The acute pain and visible deformity that can accompany dislocation would make it a consideration, especially if the finger appears misaligned. However, the absence of obvious deformity and the patient’s intact sensation makes this less likely, as dislocations usually present with more pronounced physical changes.
• Osteoarthritis
  • Osteoarthritis could be a factor, particularly given the patient’s age and medical history, but it typically presents with chronic symptoms rather than an acute injury. While it can lead to joint pain and swelling, the sudden onset of symptoms following a fall is not characteristic of osteoarthritis flare-ups. In this case, the specific details of trauma and acute pain make it a less fitting diagnosis compared to the more acute injuries from the fall.

Imaging:

• X-ray L hand
  • Osteoarthritic changes. The bones are osteopenic. Acute fracture of the proximal phalanx of the fifth finger.

Assessment 

•  75 year old female with PMHx of HTN and DM2 who presents to the urgent care today with complaints of pain in her L 5th finger following a mechanical fall. Pt denied dizziness, lightheadedness and head trauma. On exam, pt is neurovascularly intact with obvious swelling, erythema and ecchymosis of L pinky finger. There was also limited ROM of the finger due to pain. Diagnosis was concurrent with fracture of the phalanx and was supported via x-ray of the L hand.  

Diagnosis:

• Phalanx fracture

Plan

• Phalanx fracture
  • Apply finger splint and buddy taping in office
  • Refer to orthopedist for follow-up
  • OTC pain management (Ibuprofen/acetaminophen)
  • Pt education
    • Pt can return to work/activity once pain control is achieved and as long as protective buddy taping is in place.
    • The finger should be reevaluated in one week. Once the fracture is stabilized, splint can be removed and buddy taping alone is sufficient. Splint should only be used for up to 3 weeks.