STEP 2 CS -SHOULDER PAIN & NECK PAIN

LIQOR PRAAA+
WETSUFR
Weakness
exposure to cold
time of stiffness, Trauma ,Temperature, Tick's bite
Stiffness in other joints,swelling,standing long hour
ROM, Rash,redness,rheumatological history
Fatigue, Foot wear ,Fever/chills
Disability (affect his work,need help at work:?)

THEN FR CS PUB SAW ID
Trauma/headache
Headache
Edema
Nausea vomit
Fever/chills/night sweats
Rash/ Racingof heart
Chest pain,cough
SOB
Pain in joints
Urinary problem
Bowel problem(abd pain,diarhea/constipation)
Sleep pattern
Appetite
Wweight (gain lost intentional?)
Infection
Dizzy

+ PAM HUGS FOSS


shoulder pain case

DEFORMS
d: dislocation,
e: elderly abuse ,
f: fracture,
o: osteoporosis/ osteoarthritis,
r: rotator cuff tear,
m: multiple myeloma ,
s: subacromial bursitis

physical examination:

• Head and neck examination : check for bruises,neck movement

• CV examination : auscultation

• pulmonary examination : auscultation

• exam of the arms: -compare both arms in terms of strength, -ROM(shoulder,elbow,wrist),- joint stability sensation, -DTR, -pulses.
•  

PATIENT NOTES:
 HISTORY
HPI: 
74 yo male c/o right arm pain for the past 3 days.the pain started after he fell on his outstretched after he fell on his outstretched right arm and persisted despite his use of tylenol and a sling at home. No LOS before and after the fall. No paralysis or loss of sensation. the pain is in the upper and middle part of arm, increases with any mvement of the arm, and is alleviated by rest. When asked why he delayed seeking medical assistance ,the patient looked anxious and stated that his son didnt have time to take him to the hospital.

ROS: negative except as above
allergies : aspirin (rash)
medication: tylenol,albuterol inhaler
PMH ; asthma, probable BPH s/p prostate surgery
PSH : as above
SH : no smoking , no EtOH.widower for the past 3 years;lives with his son,who recently lost his job.walks 20 minutes evry morning.

PHysical examination : 
patient is in acute distress.
VS: WNL
HEENT : normocephalic, atraumatic, no bruises.
Neck : supple,full ROM in all direction, no bruises.
Chest : clear breath sounds bilaterally.
Heart : RRR, normal S1/S2; no murmurs,rubs or gallops.
Extremities: right arm held closely against chest wall. nonlocalized tenderness over middle and upper right arm and right shoulder; pain and restricted ROM on flexion,extension,abduction,and external rotation of right shoulder. right elbow and wrist are normal. pulses normal and symmetric in brachial and radial arteries. unable to assess muscle strength due to pain. DTRs intact and symmetric . sensation intact to pinprick and soft touch.

differential diagnosis
diagnosis 1 humeral fracture:
-pain following recent fall on outstretched arm 
-pain increases with arm movement
Physical exam:
-tenderness over upper and middle right arm
-restricted rom 

diagnosis 2 shoulder dislocation
-pain following recent fall on outstretched arm
-pain increase with arm movement
Physical exam findings:
-right arm externally rotated hand slightly abducted
-pain and restricted rom on shoulder exam.

diagnosis 3 : osteoporosis 
advanced age

diagnostic workup:
XR-right shoulder and arm
MRI-shoulder
Bone density scan (DEXA)

Feel

Assess temperature of shoulder joints – warmth may suggest inflammatory arthropathy/infection


Palpate the various components of the shoulder girdle (note any swelling / tenderness)

• Sterno-clavicular joint
• Clavicle
• Acromio-clavicular joint
• Coracoid process – 2cm inferior & medial to the clavicular tip
• Head of humerus
• Greater tuberosity of humerus
• Spine of scapula

 move
Put your hands behind your head – external rotation + abduction
Put your hands as far up your back as your can – internal rotation + adduction

shoulder rom
Flexion – ask the patient to raise their arms forwards until they points upwards  – 150°-170°
Extension – ask patient to keep their arms straight and extend them behind them – 40°
Abduction – ask the patient to lift their arms away from their sides as far as possible – 160°-180°
Adduction – ask the patient to bring their arms across their trunk to the opposite sides – 30°-40°
External rotation – ask patient to hold their elbows to their body flexed at 90° and then move their forearms outwards in an arc-like motion – 70°
Internal rotation –  with the patient’s elbow flexed at 90° (arm by their side) ask them to place their hand behind their back and reach as far up the spine as they can manage – Average = T5

elbow rom
flexion ,extension,pronation,supination

wrist 
flexion extension

fingers
extension ,abduction,thumb adduction


Power grip – “squeeze my fingers with your hands” Pincer grip – “place your thumb & index finger together & don’t let me separate them”


reflexes:
biceps,triceps,supinator

sensation -light touch and pin prick sensation + vibration 

Neck pain
physical examination:
neck exam : inspection,palpation,stiffness,ROM,Lhermitte's sing ,spurling test

neuro exam : motor, DTR,sensory, kernig and brudzinski