The patient is a 30-year-old male who fell about 15’ out of a tree when a branch broke. He landed on his upper back. He did not lose responsiveness. He is complaining of right shoulder and upper back pain.
Patient Exam: The patient was found on his back. He has no visible injuries. He is complaining of pain in his upper back on the spine and in the surrounding muscles. There is some tenderness around the spine right between the shoulder blades. CSM are good in all extremities.
HR 76, strong, regular
RR 18, regular, easy
SCTM pink, warm, dry
B.P. radial pulse present
Pupils equal and reactive
T° not taken, states he is warm
Medications: ibuprofen occasionally for muscle aches from exercise
Pertinent Hx: none
Last in/out: drank 4 liters of water today, urinated 2X with a normal BM
Events: The fall from the tree was not caused by a fainting event.
What is your Assessment and Plan?
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