presenting with an injury to the ___ shoulder that occurred just prior to arrival.
Patient states that the injury occurred at ___ when they fell.
Pain is described as moderate in nature.
Patient ___ has had a previous shoulder dislocation.

Associated symptoms:
Denies loss of feeling to arm.
Denies for syncope.

ROS: [Negative ] for head trauma; [10 point ROS review and negative except as otherwise indicated above ].

Physical Exam:
General: well developed patient in moderate distress.
HEENT: No head trauma, PERL, EOMI, no icterus, oropharynx clear.
Neck: NEXUS negative, normal inspection.
Back: no vertebral tenderness.
Cardiovascular: regular rate and rhythm; no rubs, murmur, gallops.
Respiratory: clear to auscultation bilaterally, normal respiratory effort, no wheezes, no JVD.
Abdominal exam: soft non-tender, no rebound, no peritoneal signs.
Neurological: alert and oriented, no vascular compromise.
Skin: warm, well perfused, no rashes, normal capillary refill, no icterus.
Psych: normal.
Extremities:
–  Shoulder: [squared off glenohumeral joint with arm held in slight abduction with external rotation. Patient has normal sensation over the deltoid, good peripheral pulses and normal capillary refill ].
–  Hand: normal inspection, non tender, normal color
–  Wrist: normal inspection, non tender, normal color, no joint swelling
–  Forearm: normal inspection, non tender, normal color, soft compartments

 

Medical Decision Making

Patient has no sign/symptoms of additional injuries.
They have been given a sling and told to follow up with their primary care physician for a referral to an orthopedist.  Return precautions have been given to the patient