The patient is a 53-year-old man who has dislocated his right shoulder three previous episodes.
QUlzti I IUN lb History of Present Illness: The patient is a 53-year-old man who has dislocated his right shoulder three previous episodes. Today, he was kayaking and dislocated his shoulder while paddling. Past Medical History: Previous right shoulder dislocation Medications: Vitamins Allergies: Sulfa Physical Examination: Alert male in no acute distress Right Upper Extremity: He has obvious deformity with loss of the right shoulder prominence with a palpable anterior dislocation of the humeral head. He has good distal pulses with the remainder of his arm being nontender. X-ray of his right shoulder shows an anterior dislocation. Diagnosis: Reduction of the shoulder dislocation. The patient was placed on a monitor with continuous pulse oximetry. He was given Demerol and Phenergan TV for pain control. In-line traction and reduction was accomplished after three attempts. Reduction films showed good position of the shoulder. He had good distal neurovascular status after reduction. He tolerated the procedure well. Disposition and Plan: Anterior dislocation, right shoulder Sling and swathe for 2 to 3 days. Vicodin #30. Follow up with Dr. Smith in l to 2 days or call for an orthopedic refen’al. The patient states he has been avoiding any potential surgery at this point and would prefer to avoid it. I explained to him that he should follow up with Dr. Smith or an orthopedist. He should not use the shoulder in the next several days until reevaluation For the toolbar, press ALT+F10 (PC) or ALT+FN+F10 (Mac). v V
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