Female, 80 years old. The left shoulder was swollen due to falling, and the activity was limited for 2 hours.
I accidentally fell down at home two hours ago, and my left shoulder was injured. My shoulder was swollen and painful, and I couldn't move. Hold your left forearm with your right hand. Unconscious disorder, dyspnea and chest and abdominal pain during the course of the disease. No defecation. He has a history of hypertension and coronary heart disease for over 10 years. Diabetes has a history of more than 20 years.
Physical examination: T36.8 degrees, P 1 13 times/minute, R23 times/minute, blood pressure168/13 mmhg. Cardiopulmonary (-). Orthopedic specialist examination: in visual order. The right shoulder is swollen and tender, the shoulder joint activity is limited, and there is no emptiness in the glenoid. Dugas's sign is negative. There is no abnormality in sensation, movement and blood supply of forearm and hand.
Auxiliary examination: X-ray film of the left shoulder joint shows that there are many fracture lines of the surgical neck of the left humerus, and there are many small bone fragments around it that are angularly displaced to the outside.
Preliminary diagnosis: fracture of surgical neck of left humerus.
Diagnostic basis:
1. Shoulder pain, swelling and upper limb dyskinesia after injury.
2. The examination showed local swelling and tenderness, and the shoulder joint activity was limited.
3. X-ray film of left shoulder joint shows that there are many fracture lines in the surgical neck of left humerus, and there are many small bone fragments around it, which are angularly displaced to the outside.
Differential diagnosis:
1. shoulder dislocation, shoulder pain and swelling. Ecchymosis, upper limb dyskinesia, but Dugas sign is negative. X-ray examination can further confirm the diagnosis.
2. Soft tissue injury of shoulder joint, shoulder pain, swelling and ecchymosis, and upper limb dyskinesia. X-ray examination can further determine whether there is a fracture or dislocation.
Step 4 check further
1. Blood routine and blood biochemistry (including blood sugar and blood lipid)
2. electrocardiogram.
3. If you need to be hospitalized, complete the relevant routine examination.
Verb (abbreviation of verb) therapeutic principle
The patient is old, has many diseases and is generally in poor condition. Manual reduction and triangle towel suspension were given for 4-6 weeks, symptomatic treatment and regular review.