Author: Jared Dixon, MD
Co Author #1: Alison Tobola, M.D.
Co Author #2: Cathy Fieseler, M.D.
Editor: Rajat Jain, MD
13 year old white male complains of right shoulder pain since yesterday. He was attending a church camp and participating in "mattress surfing," meaning he was lying on top of a mattress while it was passed overhead to a platform. He fell from the mattress, striking his right shoulder and head on the ground. He experienced loss of consciousness for "a moment." He had head and shoulder pain and felt nauseated. He also had diplopia and phonophobia. He was taken to a local emergency room (ER) where he had x-rays of his right shoulder and was told that he fractured his collarbone. His nausea and phonophobia resolved prior to arrival to the ER but diplopia persisted. No further imaging was obtained. He was placed in a shoulder sling and given recommendations to follow up with an orthopedist.
He presents to clinic wearing his shoulder sling. He reports persistent diplopia.
Review of Systems: No headache, numbness/tingling, tinnitus, dizziness, or nausea/vomiting
Past Medical History/Past Surgical History/Social History/Family History: unremarkable.
Not taking any medications.
Gen - well-nourished, no apparent distress, alert and oriented x3, head rotated slightly to the right with eye contact Case Photo #1
Head/Ear/Nose/Throat – no bony tenderness of face or head, no ecchymosis or abrasions; Tympanic Membranes normal; nares patent without discharge, oropharynx clear
Neck - nontender, full range of motion
Right shoulder - deformity of right mid-clavicle, range of motion and strength testing deferred due to injury
Neurological - Cranial nerves II-XII intact with exception of cranial nerve VI, he is unable to abduct the right eye past midline and reports diplopia with right lateral gaze Case Photo #2Case Photo #3; answers all questions appropriately; no deficits in speech, concentration, or memory
Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.