SURGICAL AUDIT

Nanjunda 55years male

Chief complaints: ℅ left shoulder pain since 4 days

Brief history : patient was apparently alright till 4 days ago, during which he had
A/H/O RTA and developed pain in left shoulder . Pain is deep seated, Pain is
increased on arm movement, decreased on rest. Radiation of pain along left upper
limb. Associated with numbness stinging sensation over left arm. Following this he
was brought to BGS GIMS for furthur management.

No H/o Loc /ENT bleed / vomiting/ pain abdomen

Past history: K/c/o HTN on medication

Not a known case of diabetes/asthma/seizure disorder

Family history: Nothing significant

Personal history:

Diet - mixed

Appetite - regular

Bowel and bladder - normal and regular

Sleep - adequate
S /E

CVS : S1,S2 heard, no murmurs.

RS : Bilateral NVBS heard,

CNS: No focal neurological deficit

P/A:- soft non tender abdomen

L/E

Attitude-patient supine, B/L shoulder equal, left upper limb adducted and flexed at
elbow
Inspection:
Contusion 5 x 6cm over proximal humerus.
Deformity present.
No scar/sinus/engorged vein seen.
Palpation:
Inspectory findings confirmed
Tenderness present.
Abnormal mobility, crepitus positive.
MOVEMENTS: shoulder movements painfully restricted.
Neurovascular:
Distal sensation normal, motor functions intact.
Pulsation normal.
Pre op xray
Post op xray
Master Vishnu Vaibhav 12 years male