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Patient Note (Rachel)

Rachel

(Patient ID 042)

Find patient record:
Name: Rachel Treatment Diagnosis:
Right fifth metacarpal fracture 		Date of Injury: __ weeks ago MR #: 000-042
Age: 43 Level of Education: Referring Physician:
Dr. Jacobs 		Insurance: BCBS
Gender Identity: Female Pronouns: she/her Race/Ethnicity:
Caucasian 		Primary Language: English
History of present illness: Fell on outstretched hands (FOOSH) while running on February 9
Past medical/surgical history: Delayed ORIF on February 15, pins removed March 1; questionable diabetes
Employment: Works part-time as a college professor
Home Environment: Lives in a two-story home with full flight of stairs to enter and full flight inside the home. Bedroom upstairs with walk-in shower, typical tub/toilet. No adaptive equipment.
Social Support: Married with four children ages 2 through 12. Husband works full-time. Her parents live nearby.

OT order February 28 for “OT evaluate and treat, AROM throughout, progress to PROM in two weeks”

Pain meds prn

February 9 – x-ray positive for 5th metacarpal fracture: minimally displaced, unstable

WBC 12 K/uL (elevated)

Presented to OT for evaluation on March 2
Presented to OT for treatment on March 9

Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.