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**CHIEF COMPLAINT:** Right shoulder injury.

**MODE OF ARRIVAL:** Private vehicle.

**HISTORY OF PRESENT ILLNESS:**
The patient is a 59-year-old male who states that just prior to arrival, he was going into a supermarket when the revolving door suddenly slammed on him. It caught him across the right side of his chest, both anteriorly and posteriorly. He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although he did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling, or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck, although he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain.

**REVIEW OF SYSTEMS:**
Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis, or cough. All other systems have been reviewed and are negative except as noted.

**PHYSICAL EXAMINATION:**

**General:**
The patient is awake and alert, lying comfortably in the treatment bed. He is nontoxic in appearance.

**Vital Signs:**
- Temperature: 98.3°F
- Pulse: 81
- Respirations: 16
- Blood Pressure: 134/81
- Pulse Oximetry: 95% on room air

**HEENT:**
The head is normocephalic and atraumatic.

**Neck:**
Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles.

**Heart:**
Regular rate and rhythm without murmurs.

**Lungs:**
Clear to auscultation bilaterally without wheezes, crackles, or rhonchi. The chest wall expands symmetrically.

**Thorax/Chest Wall:**
Demonstrates mild tenderness.

Answer :

Report on how the injury occurred and describe the cause of injury and the place of occurrence.

The injury resulted in pain across the anterior and posterior chest wall, particularly posteriorly near the scapula.

The patient reports difficulty and pain with arm movements but denies any numbness, tingling, or weakness distally. Vital signs and general physical examination are within normal limits, with no signs of respiratory distress or significant cardiovascular abnormalities noted. The head, neck, and thorax examinations reveal no acute abnormalities apart from localized pain and discomfort.

Further evaluation and possibly imaging of the right shoulder and chest may be warranted to assess for any underlying musculoskeletal injuries or soft tissue trauma.

The complete question:

CHIEF COMPLAINT: Right shoulder injury.(Patient’s complaint.) MODE OF ARRIVAL: Private vehicle.

HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.)

He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain.

REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough. All other systems have been reviewed and are negative except as noted.

PHYSICAL EXAMINATION:

General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance. Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air.

HEENT: The head is normocephalic and atraumatic.

Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles. Heart: Regular rate and rhythm without murmurs Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand symmetrically. Thorax/Chest Wall: Demonstrates mild

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