[doctor] hello , mrs . martinez . good to see you today . [patient] hey , dr . gomez . [doctor] hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? [patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm . [doctor] so you have pain in your distal radius ? [patient] yes . [doctor] how did that happen ? [patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm . [doctor] okay . and did it swell up at all ? or- [patient] it did . it got a ... it had a little bit of swelling . not a lot . [doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ? [patient] a little bit when i move my wrist . um , no numbness in my hand . [doctor] okay . do you have any past medical history of anything ? [patient] um , yes . allergic , um , l- i have allergies . and so i take flonase . [doctor] okay . and any surgeries in the past ? [patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work- [doctor] okay . [patient] on my rake . [doctor] okay . [patient] yeah . [doctor] i was wondering where you were going to go with that . [patient] yeah . [doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you . [patient] okay . [doctor] does it hurt when i press on your arm here ? [patient] yes . [doctor] okay . how about when i bend your arm ? [patient] yes . [doctor] okay . that's pretty tender , ? [patient] mm-hmm . [doctor] how about when i go backwards like that ? [patient] not as much . [doctor] and how about when i flex like this ? [patient] a little . [doctor] but mostly when i do that type of motion ? [patient] yes . [doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again . [patient] okay . [doctor] okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note . [patient] thank you .
PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.
 "