finalsession 16 shoulder pain case, upper and lower · pdf file ·...

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©University of Virginia 2008 O:\Practice of Medicine1\2007-2008\Spring Sessions\Session 16\finalSESSION 16 shoulder pain case, upper and lower extremity exam spring 2008_mentor_Oct 9.doc

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SMALL GROUP SESSION 16 January 8th or 10th

Shoulder pain case/ Touch workshop/ Upper and Lower Extremity

Examination Suggested Readings: Opatrny L. The Healing Touch. Ann Int Med 2002; 137:1003. http://www.annals.org/cgi/reprint/137/12/1003.pdf Complete the modules at the course web-site:

Principles of Musculoskeletal Exam and the Upper Extremity Exam Lower Extremity Exam

Optional: Mosby’s Guide to Physical Diagnosis- Chapters on Upper & Lower Extremity

Prepare by:

Wearing clothing for examining each others’ shoulders and upper extremities and lower extremities (tank tops, loose T-shirts, gym shorts). Someone should bring anatomy text and atlas. It will be helpful!

Brief Outline: Section 1: Touch Base (20 minutes) Section 2: Case Discussion: A Patient with Shoulder Pain (60 minutes)

Section 3: Upper and Lower Extremity Exam (Discussion 25 minutes, Examination 60 minutes)

Section 4: Evaluate Session (15 minutes)

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Section 1: Touch Base (20 minutes) Welcome back from break! Section 2: A Patient with Shoulder Pain

(Case Discussion 60 minutes) Objectives:

1. To begin to develop an approach to analyzing a clinical case. 2. To apply knowledge of shoulder anatomy

Logistics:

1. Mentors hand out cases. One student should read the history. Stop and discuss. Then read the physical exam. Continue discussion.

2. One person – the scribe – will take notes on the board. We suggest that a

mentor be scribe for this session, and that you write findings or questions in several columns:

• History • Physical findings • Anatomy • Issues (physician, patient, ethical) • Diagnostic possibilities • Laboratory and test findings, if any

3. At the end of the discussion, choose learning objectives raised by your case discussion that you would like to research and report to the group next week.


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Case Summary: A Patient with Shoulder Pain Chief Complaint: Shoulder pain HPI: The patient is a 40y/o old right-handed man who injured his right shoulder last weekend. He was skiing with his new girlfriend and fell and hurt his arm. He had planted his ski pole for a sharp turn just as he hit a patch of ice, and his arm was jerked upwards as he fell. He experienced immediate severe tearing pain in his right shoulder and wasn’t able to move it fully due to the pain. He was not able to ski for the rest of the weekend. The pain is now aching, 8/10 in severity, radiating half way down the arm, worse when attempting to use the arm and worse when lying on the right side at night. The patient is 40 years old and works in an auto parts store. He played softball in high school and continued to pitch periodically in a community intramural softball league. The patient is back at work and rather frustrated due to the pain and limited shoulder mobility. His supervisor advised him to see a doctor. Begin Discussion What structures could be affected by this injury? What might you expect to see on physical exam? What affects might this injury have on this person’s quality of life?


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Physical examination: (from the examiner’s perspective) His painful shoulder looks just like the other one. He has good muscle strength in his proximal (upper) arm muscles when his arm hangs at his side. He has tenderness at the lateral (outside) right shoulder. You can move his shoulder fully, but he winces when you raise his arm sideways from the body with the shoulder between 60 and 120 degrees. When you hold the arm raised at 90 degrees (straight out from the shoulder) and let go, it falls (a positive drop arm test). He says it isn’t only pain that keeps him from holding his arm up; he just can’t. A few suggested questions: 1. What could these physical findings mean? 2. What could have happened to his shoulder? Think of the specific bones, joints, ligaments and muscles that might have been injured. 3. How might you be able to find out what is the matter?

4. How might this injury affect him?


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SECTION 3: UPPER AND LOWER EXTREMITY EXAMINATION AND TOUCH WORKSHOP (Discussion 25 minutes, Examination 60 minutes) Objectives:

1. To discuss the role of touch in physician-patient interactions 2. To discuss how to approach a patient from a different culture about issues

related to the physical examination 3. To learn the upper and lower extremity examination

1. Touch workshop: In examining the upper and lower extremity, you will be touching each other in a medical context. Before doing this, take a few minutes to discuss touch. Long before physicians and modern medicine, touch has been associated with healing. It can be a literal way to make contact and express caring, as well as one of a physician’s tools to diagnose disease. Touch also has different meanings in different cultures. For example: some of you may feel uncomfortable, for cultural or personal reasons, being touched by someone of opposite (or the same) gender. If so, tell your mentors! Some things you may want to discuss before you touch each other: 1. What is your own reaction to touch by a stranger? By a friend? By a doctor? 2. How do your family background, cultural context and individual personality

contribute to your reaction to touch? 3. What potential issues might arise during examination of an individual from another

culture? How should this be approached? 4. How do you feel about touching others when you are the examiner? Do particular

situations make you more or less uncomfortable? 5. As you are examined during this session: how do you feel? Why?


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EXTREMITY EXAMINATION Review the following characteristics assessed during a musculoskeletal exam:

• range of motion • signs of inflammation (redness, warmth, swelling, pain) • crepitus • deformities • condition of surrounding tissues • muscular strength • symmetry

Review the techniques used to evaluate the joints and surrounding soft tissues:

• inspection • active range of motion • palpation • passive range of motion • strength testing • special maneuvers

UPPER EXTREMITY EXAMINATION: This will include: inspection, range of motion, palpation, and strength, as well as a few special tests. 1. The shoulder:

• inspect for symmetry, deformity and discoloration • do range of motion: abduction, adduction, flexion, extension, internal

rotation, external rotation • palpate surface landmarks: the scapular spine, acromion,

acromioclavicular joint, clavicle and bicipital groove • assess strength: ask patient to shrug shoulders, flex shoulder and

abduct shoulder against your resistance. 2. The elbow:

• inspect for symmetry, deformity and discoloration • do range of motion: flexion, extension, pronation, supination • palpate for swelling or tenderness; palpate for crepitus during motion • assess strength: have patient flex and extend elbow against resistance • Maneuvers of the elbow: palpate for tenderness at the lateral

epicondyle (a sign of lateral epicondylitis – “tennis elbow”) and medial epicondyle.


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3. The wrist and hand: • inspect for symmetry, deformity and discoloration; assess thenar and

hypothenar eminence • do range of motion: flexion, extension, flexion toward the ulna and

toward the radius, flexion and extension at metacarpophalangeal (MCP) joints, and make a fist

• palpate wrist, carpometacarpal (CMC), MCP and proximal interphalangeal (PIP) joints for swelling or tenderness

• assess strength: have patient flex and extend wrist against resistance, grip your fingers, abduct fingers and hold together thumb and small finger (opposition) against resistance

• Special maneuvers of the wrist (optional): • Tinel’s sign: tap on the palmar side of the wrist; in carpal tunnel

syndrome, this elicits pain and tingling into the hand • Phalen’s sign: patient holds wrist flexed at 90 degrees for one minute.

In carpal tunnel syndrome, this causes pain and tingling in the hand


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LOWER EXTREMITY EXAMINATION Goal: To learn how to examine the lower extremity, with a special emphasis on the examination of the knee. Objectives: A. Describe and demonstrate the examination (inspection, palpation, range of motion)

of normal joints of the lower extremity: • foot and ankle: tibiotalar, subtalar, transverse tarsal and

metatarsophalangeal joints • knee • hip, including assessment of proximal muscle strength through

observation of standing from a sitting position B. Describe and demonstrate and know the significance of the following components

of the knee exam:

• Lachman test and anterior drawer tests • posterior drawer tests • varus and valgus stress • McMurray test

Exam: 1. The hip and pelvis:

• assess strength: ask patient to stand from a sitting position • inspect for symmetry, deformity and discoloration while standing • palpate surface landmarks: palpate the iliac crest and greater trochanter • do passive range of motion: abduction, adduction, flexion, extension,

internal rotation, external rotation of the hip 2. The knee:

• inspect for symmetry, deformity and discoloration • palpate for swelling or tenderness along the joint lines, the patella and

the popliteal space. Palpate for crepitus during motion • do range of motion: flexion and extension • assess strength: have patient flex and extend knee against resistance • Maneuvers of the knee –

o Assess mediolateral instability: support leg and stabilize knee. Apply a varus and valgus stress, and evaluate the lateral and medial collateral ligaments, respectively, for pain or laxity

o Assess cruciate ligament: Flex knee to 30° (Lachmann) or to 90° (anterior drawer), stabilize the lower leg, and pull the lower leg towards you and watch for anterior movement of the tibia. With the leg flexed to 90° and while stabilizing the lower leg, push the


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lower leg towards the patient while assessing for posterior movement of the tibia (posterior drawer).

o Assess meniscal cartilage (McMurray test): flex knee and hip, support knee with one hand. With other hand internally rotate and extend knee, then flex knee and externally rotate and extend knee. Feel for pain and/or a popping sensation.

3. The foot and ankle: • inspect for symmetry, deformity and discoloration • palpate achilles tendon, lateral and medial malleoli and mid-foot and

forefoot. • do range of motion: extension (plantar flexion), flexion (dorsiflexion),

inversion (adduction) and eversion (abduction). • assess strength: have patient plantar flex, dorsiflex, evert and invert foot

against resistance. SECTION 4: Evaluate Session (15 minutes) Continue the touch discussion. What was it like examining a classmate? Being examined by a classmate? How will examining a patient be different?


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Physical Diagnosis Objective Structured Clinical Examination (OSCE)

Upper Extremity Exam

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt

Procedure A B C Comments

1. SHOULDER Inspection: Assess symmetry, deformity and discoloration. (Ex states what they are inspecting for)

2. SHOULDER Range of motion: Examiner asks patient to flex, extend, abduct (full arc), internally rotate (elbow flexed, thumb at opposite scapula) and externally rotate (elbow flexed, hands out at sides or behind head) both shoulders.

3. SHOULDER Palpation: Ex. palpates scapular spine, acromion process, acromioclavicular joint and bicipital groove (one side OK).

4. SHOULDER Strength: Ex resists patient while patient shrugs shoulders, flexes shoulder forward and abducts shoulder.

5. ELBOW Inspection: Assesses symmetry, deformity and discoloration. (Ex states what they are inspecting for)

6. ELBOW Range of motion: Pt. flexes, extends, pronates, (elbow at 90, palm down) and supinates (elbow at 90, palm up) both elbows.

7. ELBOW Palpation: Ex. palpates lateral epicondyle, medial epicondyle and olecranon process (one side OK).

8. ELBOW Strength: Ex. resists patient while patient flexes and extends elbow.

9. WRIST and HAND Inspection: Assesses symmetry, deformity and discoloration. Assesses thenar and hypothenar eminence. (Ex states what they are inspecting for)

10. WRIST and HAND Range of motion: Pt flexes and extends wrist. Pt moves hand to ulnar and radial sides. Pt flexes and extends fingers at MCP joint with fingers straight, and makes fist.

11. WRIST and HAND Palpation: Ex. palpates wrist, CMC, MCP and PIP joints.

12. WRIST and HAND Strength: Ex. resists patient while patient flexes and extends wrist, assesses grip strength, resists finger abduction, and resists opposition of thumb and small finger.


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Physical Examination Objective Structured Clinical Examination (OSCE)

Lower Extremity Exam

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments

1. INSPECTION:

a. Examiner assesses strength of hip muscles by asking patient to rise from chair.

b. Examiner assesses hips, knees, ankles and feet for symmetry, deformity and discoloration while patient is standing.

2. HIP Palpate: Ex palpates iliac crest and greater trochanter.

3. HIP Range of motion: (Passive)

a. Flexion – with the patient supine, Ex flexes the patient’s hip with knee bent.

b. Extension (prone or standing) – Ex extends patient’s hip.

c. Adduction and abduction – with patient supine, Ex adducts and abducts patient’s hip.

d. Internal and external rotation – with patient supine and knee flexed to ~90°, Ex internally and externally rotates patient’s hip.

4. KNEE Inspect: Ex inspects knee with patient supine for swelling and discoloration.

5. KNEE Palpate: Ex palpates popliteal space, tibiofemoral joint space laterally and medially, and patella.

6. KNEE Range of motion: Ex asks patient to flex and extend knee.

7. KNEE Strength: Ex resists patient while patient flexes and extends knee.

8. KNEE Special maneuvers:

a. Mediolateral instability – Ex flexes knee to 30° and applies varus and valgus stress to knee, assessing for medial and lateral laxity.

b. Cruciate ligament: Lachman test – Ex flexes knee to 20° to 30°, grasps the distal thigh above the patella with one hand (thumb should wrap over thigh just above patella), grasps proximal tibia with other hand and pulls tibia anteriorly.

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Cruciate ligament: Drawer test – Ex flexes knee to 90°, stabilizes foot by lightly sitting on it, and pulls tibia anteriorly for anterior drawer test, and also pushes posteriorly for posterior test. (Ex may choose which cruciate test to perform)


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c. McMurray test (included only for small group use, not for testing) – Ex flexes knee completely, encircles joint space with thumb and index finger, rotates foot laterally, and extends knee. Maneuver should be repeated with medial rotation of foot.

9. ANKLE and FOOT Inspection: Ex inspects feet and ankles without shoes or socks for deformity or discoloration.

10. ANKLE and FOOT Palpation: Ex palpates Achilles tendon, lateral and medial malleoli and forefoot.

11. ANKLE and FOOT Range of motion: Ex asks patient to dorsiflex, plantar flex, evert and invert the ankle.

12. ANKLE and FOOT Strength: Ex resists patient while patient dorsiflexes and plantar flexes ankle. Ex also resists inversion and eversion.

finalsession 16 shoulder pain case, upper and lower · pdf file ·...

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