History of Present Illness:

34 y/o M, with no PMHx, who presents to the ED via EMS with left arm pain after he was riding his bicycle and a car door opened and pinned him between another car. Patient does not know how fast he was riding his bike and reports he was wearing a helmet. He states he was able to ambulate after the incident. He denies loss of consciousness, neck pain or head trauma. He reports a left shoulder laceration where he believes the car door hit him. Patient also reports left shoulder pain, stating he has pain when trying to move it. He does not remember his last tetanus shot. He denies headache, chest pain, shortness of breath, abdominal pain, nausea, vomiting, dizziness or other extremity pain.

PMHx: none

Medications: none

PSHx: none

FMHx: non-contributory

Social History: Drinks 1-2 alcoholic beverages a month, denies smoking or drug use. Lives with his significant other.

Allergies: NKDA

Review of Systems:

Gen: Denies fever, chills, fatigue, weakness or change in appetite.

Resp: Denies cough, wheezing, hemoptysis, shortness of breath.

CV: Denies chest pain, palpitations, leg swelling.

GI: Denies abdominal pain, distention, nausea, vomiting, diarrhea, constipation.

GU: Denies polyuria, difficulty urinating, dysuria, flank pain, hematuria

MSK: Admits to left shoulder pain. Denies back pain, neck pain or change in gait.

Skin: Admits to left shoulder laceration and right thigh abrasions. Denies any rashes

Neuro: Denies headache, dizziness, loss of consciousness, weakness or numbness/tingling.

Physical Exam:

VS: T 98.6F, BP 150/83, HR 66, RR 18, O2 saturation 98%, Wt 185 lb, Ht 5’10”, BMI 26.54

Gen: Alert and oriented x3, in no acute distress. Sitting upright in chair with left shoulder in sling.  

Skin: Warm and dry. Not diaphoretic. Abrasions to right thigh. 3 cm linear laceration to anterior left shoulder with no active bleeding.

HEENT: Normocephalic, atraumatic. PERRLA. EOMIs, no nystagmus.

Resp: Clear to auscultation bilaterally

CV: Regular rate and rhythm

Abd: Soft, nondistended, nontender. Normoactive bowel sounds.

MSK: Left upper extremity in sling on arrival. Limited ROM of left shoulder secondary to pain, difficulty abducting the shoulder. Pain to palpation of left shoulder, with no gross deformities. Pain with flexion of the left elbow. FROM of left hand. Full range of motion and 5/5 strength to RUE, RLE, LLE.

Neuro: No focal neuro deficits.

Differentials: Left humerus fracture, left shoulder sprain/strain, left elbow fracture, laceration

Assessment:

34 y/o M, with no PMHx, who presents after he got hit by a car door while riding his bike with complaints of left shoulder pain and a left shoulder laceration, with limited range of motion of the left shoulder on exam due to pain.

Plan:

XR left shoulder

XR left elbow

XR left humerus

Administer tetanus  

Administer Flexeril and Tylenol

Repair left shoulder laceration

Laceration Repair Note:

Date/Time: 3/25/21 7:00 PM

Consent obtained: Verbal

Consent given by: Patient

Risks discussed: infection, pain and poor wound healing

Alternatives: no treatment

Anesthesia: local infiltration with lidocaine 1% with epi

Laceration: 3 cm on left shoulder

Repair: Simple

Preparation: Patient prepped and draped in sterile fashion

Contaminated: no

Area cleansed with: saline and betadine and irrigated with sterile water

Skin repair: 3-0 Nylon, 4 simple interrupted sutures. Close approximation

Post procedure: Antibiotic ointment and sterile dressing. Patient tolerated well with no immediate complications

Addendum:

XR left shoulder: Questionable lucency at the head neck junction of humerus may represent nondisplaced fracture. Soft tissue swelling

XR left humerus: Questionable lucency at the heck neck junction of the humerus, correlate for nondisplaced fracture.

XR left elbow: No apparent fracture or joint effusion at the elbow joint.

Patient received tetanus shot. Declined pain medication while in the ED. Left shoulder laceration repaired. Patient placed in left shoulder sling.

Disposition:

Patient is clinically stable. Will be discharged home.

Orthopedic surgery referral for further management.

Instructed the patient to return to the ED in 7 days for suture removal.

Patient placed in left shoulder sling.

Tylenol and Ibuprofen will be sent to the pharmacy for pain as needed.

Patient Education:

The x-rays taken of your left elbow did not show any signs of a fracture. The x-ray of your shoulder and humerus showed the possibility of a nondisplaced, not shifted out of place, fracture at the top of your humerus. At this time, you will be placed in a left shoulder sling and should follow up with orthopedics. A referral was placed for you. The orthopedist will do additional imaging if they find necessary and follow up with you in regard to how long you should stay in a sling, if needed. A laceration repair on your left shoulder was also done today. You received four stitches, which need to be removed in 7 days. You should return to the ED at that time for removal of the sutures. If you have any worsening pain to your shoulder, any changes to sensation to your left arm, warmth, redness or discharge from your laceration or a fever, you should return to the emergency department. Take the Tylenol and Ibuprofen as needed for pain.