1 / 18

Arm Injury A Case Discussion

Arm Injury A Case Discussion. Case Presentation. Patient History. General Data. TO 14 year old male Lives in Palau Right-handed Informant: Patient, good reliability Chief Complaint: Wrist Injury. History of Present Illness . Fall 2 nd floor of house ~ 20ft

len
Download Presentation

Arm Injury A Case Discussion

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Arm Injury A Case Discussion

  2. Case Presentation Patient History

  3. General Data • TO • 14 year old male • Lives in Palau • Right-handed • Informant: Patient, good reliability Chief Complaint: Wrist Injury

  4. History of Present Illness Fall 2nd floor of house ~ 20ft hitting R hand, fully extended • on sandy surface (+) loss of consciousness for a few seconds (+) deformity on R wrist 8 days PTA

  5. History of Present Illness Consult at local hospital X-ray revealed fracture of the distal radius Given Tramadol Discharged (no ortho) (-) Change in sensorium (-) Nausea, vomiting, seizure (-) numbing of R hand 8 days PTA Admission

  6. Review of Systems General: no weight loss, Cutaneous: no lesion, no pruritus HEENT: with occasional headaches no redness no aural/nasal discharge no neck masses no sore throat Cardiovascular: no easy fatigability, fainting spells, no palpitation Respiratory: no cough, colds Abdominal: no change in bowel movement Genitourinary: no change in urination Endocrine: no polyuria, polydypsia, no heat/cold intolerance Hematopoietic: no easy bruisability, or bleeding

  7. Past Medical History • No asthma, hypertension, diabetes, allergies,heart disease, bone diseases • No maintenance medications • No previous surgeries • Does not recall previous immunizations • Hospitalized > 5 years ago 2o AGE

  8. Family History • Diabetes Mellitus, Heart Disease • No hypertension, asthma, cancer, stroke, or allergies

  9. Personal/Social History • 1st year high school student • Lives with his family in a 2 story house in Palau • Denies smoking, alcohol drinking, and drug abuse

  10. Case Presentation Physical Exam

  11. Physical Exam • General Survey • Awake, active, and not in cardiorespiratory distress • Vital Signs • Febrile at 37.5oC • RR 20 bpm • HR 71 bpm • Height:168cm weight:59kg BMI: 20.9

  12. Physical Exam • Skin • Dirty skin • No rashes, hemorrhages, scars • Moist • CRT 1-2 seconds

  13. Physical Exam Head no lesions Eyes anictericsclerae, slightly pale palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum midline, moist mucosa Throat mouth and tongue moist no TPC

  14. Physical Exam Neck no cervical lymphadonapathy supple Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 5th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

  15. Physical Exam Abdomen flat, no scars, no lesions normoactive bowel sounds tympanitic on all quadrants Soft nontender no masses, no organomegally

  16. Physical Exam Right upper extremity Shoulder and Elbow no deformity, no asymmetrical no discoloration, no lesions no tenderness, no swelling no limitation of movement full ROM

  17. Physical Exam Right upper extremity posteriorly deformed distal forearm bluish discoloration on the anterior wrist no lesions tenderness around the wrist Soft tissue swelling of the anterior wrist wrist ROM limitation due to pain intact radial, median, and ulnar nerves (motor and sensory) allen’s sign? ROM limitation due to pain

  18. Salient Features History • 14 year old male • LLQ  RLQ pain • Nausea, vomiting, fever, anorexia Physical Exam • RLQ direct and rebound tenderness • Rovsing’s sign • Psoas sign

More Related