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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

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Presentation Transcript
case presentation
Case Presentation

Patient History

general data
General Data
  • TO
  • 14 year old male
  • Lives in Palau
  • Right-handed
  • Informant: Patient, good reliability

Chief Complaint: Wrist Injury

history of present illness
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

(–) break in skin

(–) bruising

8 days PTA

history of present illness1
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

review of systems
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

past medical history
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
family history
Family History
  • Diabetes Mellitus, Heart Disease
  • No hypertension, asthma, cancer, stroke, or allergies
personal social history
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
case presentation1
Case Presentation

Physical Exam

physical exam
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
physical exam1
Physical Exam
  • Skin
    • Dirty skin
    • No rashes, hemorrhages, scars
    • Moist
    • CRT 1-2 seconds
physical exam2
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

physical exam3
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

physical exam4
Physical Exam

Abdomen

flat, no scars, no lesions

normoactive bowel sounds

tympanitic on all quadrants

Soft

nontender

no masses, no organomegally

physical exam5
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

physical exam6
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

salient features
Salient Features

History

  • 14 year old male
  • R-handed
  • 8 days PTA
    • Fall from 20ft on sand
    • Right arm extended
    • (+) R wrist deformity
      • (–) break in skin
      • (–) bruising
    • (–) R hand numbness
    • Immobilized with short posterior arm splint

Physical Exam

  • Right upper extremity
    • posteriorlydeformed distal forearm
    • bluish discoloration on the anterior wrist
    • (–) external lesions noted
pre operative diagnosis
Pre-Operative Diagnosis
  • Fracture, closed, complete, transverse, displaced, distal radius, Right
procedure done
Procedure Done
  • Closed reduction, percutaneous pinning, application of long arm cast, Right
post operative diagnosis
Post-Operative diagnosis
  • Fracture, closed, complete, transverse, displaced, ulnarstyloid, Right
  • Distal radius and ulna styloid fracture, Right