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Kornhauser Health Sciences Library

David Hall: The Case

 

The Case

 

HPI:

David Hall is a 32-year-old patient who comes to the emergency department at 11 pm on a Tuesday complaining of pain and numbness of his left arm after falling while walking down steps.

He was leaving a party with some friends when he tripped and fell down about 5 steps, landing on his left shoulder and back. He says he felt a “popping and tearing” with severe pain in the shoulder starting immediately. His friends picked him up off of the ground and brought him to the ER when he tried to move his arm and could not.

He describes stabbing pain in the left shoulder as 8/10 in severity.  He reports some numbness in the left arm.   No neck pain.  Arm pain is worsened with movement, partially alleviated by keeping the arm completely still.  No problems with his arm before his fall.  He is right-handed. 

Past Medical History: He says he is otherwise healthy.

Past Surgical History: None

Medications: Occasional acetaminophen for pain

Allergies: None

Family history: His father has had a heart attack, bypass surgery, and has some kind of liver disease. His mom has diabetes, and his brother has had blood clots and has to be on a blood thinner.

Social History: He drinks beers with his friends several nights a week, smokes a pack of cigarettes a day.  He is separated from his wife of 5 years and lives in an apartment. He works as a foreman in a heavy equipment and tractor manufacturing plant and is very worried about being able to work if he is injured. He has health insurance through his work.

ROS:  He denies hitting his head, feeling light-headed or having pain anywhere else.  No abnormal bleeding.

Physical Examination:

Vitals
Test Value
T 98.6
HR 125
BP 155/85
Spo2 99%

HEENT: pupils reactive and equal, EOMI, no neck pain with palpation of spinous processes, full neck range of motion without pain. No abrasions or contusions on scalp palpation or on face. No JVD.

Thorax: bruising, TTP over left posterior thorax. Lung sounds equal bilaterally.

CV: RRR, pulses 2+ in all extremities, good perfusion and capillary refill

Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly.

MSK: Full cervical range of motion.  Left shoulder held in abduction and external rotation and contour of shoulder is abnormal. Strength testing and passive range of motion of the shoulder is limited by pain.  Left wrist drop noted as well as decreased sensation to light touch, temperature, and pinprick in a patchy distribution over the posterior left forearm and hand. Right arm, both legs with normal passive and active range of motion, strength and sensation to light touch.

Workup:

An x-ray of the left shoulder is shown in X-ray #1:

X-ray of left shoulder

David is given IV pain and sedation medications and the ER physician and a nurse place his shoulder back into the proper alignment.

A follow-up x-ray is taken.  X-ray #2:

x-ray of left shoulder

Repeat physical exam after sedation has worn off shows decreased strength with left shoulder abduction, external rotation, decreased strength of elbow extension and flexion, wrist extension, finger extension, and decreased sensation over the left lateral shoulder and posterior arm and hand.  Wrist and finger flexion is normal, as is sensation on the anterior forearm and hand.

David is placed in a sling and swathe, instructed to avoid bearing weight with the arm or painful movement until he is seen by an orthopedic doctor. He is given an appointment in 2 days and discharged from the ER.

Follow-up:

David is seen by the orthopedic surgeon 2 days after his injury. His examination of his left arm is unchanged. He is very upset about his inability to use his left arm. His employer instructed him to complete FMLA paperwork, which he brought for the doctor to sign (included). He needs that paperwork filled out at the visit today so he does not get fired for being unable to work the last 2 days since being injured. He also wants to know how long he has to keep the sling and swathe on, and if the weakness and numbness is going to get better or he should apply for permanent disability. 

Clinical Librarian

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Ansley Stuart
Contact:
Health Science Campus
Kornhauser Library, Rm 204
502-852-8534

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