**Emergency Room Report**
**Patient Name:** Irma Kennedy
**Birth Date:** 03/01/XX
**Patient Number:** 02-02-34
**Room Number:** ER
**Date of Visit:** 05/10/20XX
**Chief Complaint:**
Left wrist injury.
**History of Present Illness:**
An 82-year-old white female presents with a left wrist injury. The patient states that her shrubs have not been trimmed, and she was trying to get in between them on a ladder, and fell. She fell against her left hand. She complains of pain over the left wrist. There is no numbness or tingling in the hand. The patient does have a limited range of motion secondary to pain.
**Physical Examination:**
- Temperature: 36.3
- Pulse: 85
- Respirations: 18
- Blood Pressure: 158/88
General: Alert, well-developed, well-nourished, elderly white female in no acute distress.
HEENT: Normocephalic, atraumatic. Neck is supple, nontender.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm.
Abdomen: Soft, nontender.
Extremities: Warm and dry. The patient does have a gross obvious deformity to her left wrist with swelling and posterior angulation. The pulses were palpable. She had brisk capillary refill and sensation in all her fingers. There is no tenderness over the anatomical snuffbox. Her pain was over the distal radius and ulna. Range of motion was limited secondary to pain. The patient could not fully flex, extend, or abduct her fingers secondary to pain. Otherwise, she was neurovascularly intact.
**Treatment:**
X-rays of the left wrist, 3 views, showed a comminuted, intra-articular Colles fracture. There is 10 degrees of angulation, apex volar, wrist is shortened by 2-3 cm, displaced approximately 1 cm ulnarly. Dr. Michael, the orthopedic surgeon, was called, and he reduced the fracture and put her in a splint. The patient was initially given fentanyl 25 mcg IM for pain. During the reduction, she was given an additional 25 mcg of fentanyl. Please refer to Dr. Michael's dictation for details of the procedure.
**Diagnosis:**
Left comminuted, intra-articular Colles fracture.
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1. **What brought the patient to the emergency room?**
The patient presented with a left wrist injury after falling while trying to trim her shrubs.
2. **What were the patient's main symptoms related to her wrist?**
The patient complained of pain over the left wrist, limited range of motion, but no numbness or tingling.
3. **What were the physical exam findings pertinent to her injury?**
The physical exam revealed gross obvious deformity, swelling, posterior angulation of the left wrist, and pain over the distal radius and ulna with limited range of motion.
4. **What did the x-rays reveal?**
X-rays showed a comminuted, intra-articular Colles fracture with 10 degrees of angulation, wrist shortening by 2-3 cm, and displacement approximately 1 cm ulnarly.
5. **What treatment was provided and with what result?**
Dr. Michael, the orthopedic surgeon, reduced the fracture and put the patient in a splint. The patient was given fentanyl for pain management.
