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Leg Injury Case Study

Satisfactory Essays

CHIEF COMPLAINT: Left shoulder and left lower leg injury.

HISTORY OF PRESENT ILLNESS: Ms. Branson is here today for followup evaluation of her left tibial shaft fracture for which she underwent operative stabilization with intramedullary nailing and small medial plate, three weeks ago. She also sustained a grade 3 AC joint separation on the left at the time of injury. She has been attending physical therapy and has shown excellent progress with her range of motion in the shoulder. She remains nonweightbearing on the left lower extremity, as instructed, and is tolerating this well. She has not required any pain medication, other than over the counter anti-inflammatories for the last one to two weeks and feels good with her progress.

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