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Nurse Note: Patient brought in by mom because he stepped on a nail.
HPI:15-year-old male brought in by mom with foreign body in his foot. The occurrence was today at 11 am. Location: RT foot. Degree of pain is moderate. Degree of dysfunction: Pain with weight bearing. Stepped on a rusty nail while walking bare foot in the garage and went approximately 0.5 inches into the RT foot.
PAST Medical/Family/Social History
Medical History: Vaccinations reviewed, Tetanus is not up to date.
General Appearance: Mild Distress
Heart: Regular rate and rhythm, no extra heart sounds
Respiratory: Lungs Clear to auscultation bilaterally
Extremity: Normal range of motion. Normal tone. Puncture wound sole of the foot at the first toe, swelling and redness to anterior foot, there is a small rusty nail embedded in the subcutaneous tissue.
FROM of ankle and toes.
Rx: Keflex 500 mg, Ibuprofen 600 mg
Foreign body in foot
Verbal consent obtained. Area anesthetized with Lidocaine 2% without epinephrine, 2 ml used. Foreign body was removed by making a small incision and removing with forceps. Bleeding controlled, steri-strips and dressing applied. Patient tolerated procedure well.
J Smith, MD