AC H&P 1

Chief Complaint:

“Painful swelling around my nail” x 3 days

History of Present Illness:

34 y/o male with no significant PMHx presents with a painful swelling around the left middle finger nail for the past 3 days. The patient reports onset of redness and tenderness around the nail, which has progressively worsened. He describes the pain as throbbing, 7/10 in intensity, and notes that it has made it difficult to use his left hand effectively. Patient denies fever or systemic symptoms. Patient states he applied warm compress to the area without significant improvement.Patient states he works in the metal industry and is not sure if something got stuck in his finger. Denies any recent injuries to the nail or hand, but does recall frequent handwashing and minor nail-biting habits. Denies seeing any drainage/odor from the area. 

Patient reports being up-to-date with his tetanus vaccination, received within the last 10 years.

Past Medical History:

  • No significant past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No current medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food or environmental allergies

Family History:

  • Mother: Alive and well, no significant PMHx
  • Father: Alive and well, no significant PMHx
  • Maternal grandparents: Unknown
  • Paternal grandparents: Unknown

Social History:

  • Smoking: Non-smoker
  • Substance use: Denies alcohol or drug use
  • Caffeine: Consumes 1-2 cups of coffee daily
  • Occupational history: Works in a metal industry 
  • Home situation: Lives at home with his wife.

Review of Systems:

  • General: Denies generalized weakness, fever, chills, night sweats, weight loss or gain.
  • Skin, hair, nails: Admits to swelling and redness around the left middle finger nail. Denies other changes in texture or color.
  • Head: Denies head trauma, vertigo.
  • Ears: Denies ear pain, discharge, tinnitus.
  • Nose: Denies nasal congestion, discharge, epistaxis.
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies swelling, stiffness, decreased ROM.
  • Cardiovascular: Denies chest pain, palpitations, irregular heartbeat.
  • Pulmonary: Denies cough, dyspnea, wheezing.
  • Gastrointestinal: Denies nausea, vomiting, abdominal pain.
  • Genitourinary: Denies urinary symptoms.
  • Musculoskeletal: Admits to pain in the left middle finger, no other joint pain or swelling.
  • Nervous system: Denies seizures, headache, sensory disturbances.
  • Peripheral vascular: Denies color changes, peripheral edema.
  • Hematologic: Denies easy bruising or bleeding.
  • Endocrine: Denies symptoms of thyroid dysfunction.
  • Psychiatric: Denies depression, anxiety.

Physical Exam:

  • Vitals:
    • BP: 134/81 (seated, right arm)
    • HR: 82 BPM (regular)
    • RR: 16/min (unlabored)
    • T: 98.1 F (oral)
    • O2: 97% (room air)
    • Height: 6’1 Weight: 230 lbs BMI: 30.4
  • General: AAO x 3, appears in mild distress due to pain, well-groomed.
  • Skin: Warm, moist; good turgor; non-icteric: paronychia left middle finger (swelling, redness and tenderness to palpation of DIP area of left middle finger under the nail bed.).
  • Head: Normocephalic, atraumatic, non-tender to palpation.
  • Eyes: Conjunctiva pink. PERRLA. Visual fields full OU.
  • Ears: TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge, or foreign bodies.
  • Nose: Symmetrical, no deformities. No nasal discharge or congestion.
  • Mouth: Mucosa pink and well-hydrated.
  • Pharynx: No erythema, exudates, or lesions. Uvula midline.
  • Neck: Trachea midline. Supple and non-tender to palpation. No cervical adenopathy.
  • Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.
  • Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.
  • Lungs: Clear to auscultation bilaterally.
  • Abdomen: Abdomen flat and symmetric, no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, non-tender, no guarding or rebound noted.
  • Nervous System: Cranial nerves I-XII intact.
  • Peripheral Vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis, or edema noted.
  • Musculoskeletal: Full range of motion (FROM) of all upper and lower extremities bilaterally. 

Differential Diagnosis:

  • Paronychia
  • Cellulitis
  • Felon (subungual abscess)

Workup:

  • None indicated at this time. Clinical diagnosis based on physical examination.

Diagnosis:

  • Acute Paronychia

Assessment:

34 y/o male with a 3-day history of painful swelling and redness around the left middle finger,right under the nail bed. Exam shows erythema, swelling, and tenderness around the nail, with no systemic symptoms. No signs of systemic infection or abscess.

Plan:

  • Treatment:
    • Oral antibiotics: Amoxicillin-Pot Clavulanate Tablet, 875-125 MG, 1 tablet, Orally, every 12 hrs, 10 day(s), 20, 
    • Warm water soaks: 3-4 times daily for 15 minutes to promote drainage
    • Pain management: OTC Tylenol or ibuprofen as needed for pain
  • Patient Education:
    • Importance of hand hygiene and avoiding nail-biting
    • Signs of worsening infection or systemic involvement (e.g., fever, increasing redness, or swelling)
  • Follow-Up:
    • Return to the clinic if symptoms worsen or do not improve within 48-72 hours
    • Seek immediate care if fever, significant pain, or signs of systemic infection develop