Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right arm pain following [mechanism of injury, e.g., fall onto outstretched hand/direct trauma]. Reports localized swelling, deformity, and inability to bear weight or move the right upper extremity. Denies numbness or tingling in the hand. Pain is rated [0-10]/10, exacerbated by movement.
Clinical Examination Findings
Right upper extremity: Obvious deformity and soft tissue swelling noted at the mid-shaft humerus. Tenderness to palpation over the fracture site. Distal neurovascular status intact: radial pulse 2+, capillary refill <2 seconds, sensation intact to light touch in radial, ulnar, and median nerve distributions. No signs of compartment syndrome.
Treatment Protocol
Immobilization with a coaptation splint or humeral brace. Pain management with NSAIDs and analgesics. Orthopedic follow-up scheduled for [Date/Time] for repeat radiographs to assess alignment. Strict instructions to monitor for neurovascular compromise.