Physical Examination and Workup
On presentation to the ED, the patient is noted to be in moderate discomfort secondary to multiple abrasions and contusions. Upon initial examination, findings are largely unremarkable. He has a regular pulse of 95 beats/min, a respiratory rate of 18 breaths/min, a blood pressure of 115/80 mm Hg, an oxygen saturation of 99% while breathing room air, and an oral temperature of 97°F. He is maintaining his airway, has good breath sounds bilaterally, and has a Glasgow Coma Score of 15.
Upon further examination, however, tenderness is noted in his right-shoulder region, with mild swelling of the general shoulder region. Although the shoulder joint is observed to move normally, crepitus is observed upon palpitation.
No open wounds and no deformities are noted over the affected area. The peripheral arterial pulses in the right extremity are normal. No neurologic deficits are noted in the extremity, and the axillary nerve is normal. Examinations of the chest wall, scapula, sternum, and the remaining distal regions of the extremity are also unremarkable.
All laboratory investigations, including a complete blood cell count and a basic metabolic panel, are within normal limits. Of the imaging studies that the patient undergoes, radiographs of the right shoulder and chest (Figures 1, 2, and 3) are interpreted as normal.
The patient is subsequently admitted for observation and pain control; he is then discharged a few days later from the trauma service. At the time of discharge, he is still experiencing right-shoulder pain. A discharge diagnosis of shoulder contusion is assigned, and no further imaging or other investigations are performed on his shoulder.
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