jurnal #7
DESCRIPTION
Jurnal #7TRANSCRIPT
Shoulder Pain as an Unusual Presentation of Pneumonia in a Stroke Patient: A Case Report
Wannapha Petchkrua, MD, Stacy A. Harris, MD(Arch Phys Med Rehabil 2000;81:827-9)
Deta Tanuwidjaja, dr.Department of Physical Medicine & RehabilitationFaculty of Medicine Universitas Padjadjaran
Supervised by: Irma Hassan Hikmat, dr., SpRad(K).
7th Journal ReadingJuly 10th, 2013
INTRODUCTION
Shoulder Pain in hemiplegia
most frequent complication
Impairment Disability Handicap
• 38-70 % incidence of HSPGriffin
• 41 % HSP 3years post stroke 48% unspecifiedPoduri
INTRODUCTION
Totta & Beneck
Glenohumeral subluxation
Frozen shoulderImpingement
syndromeRotator cuff lesions
Brachial plexus neuropathy
Reflex sympathetic dystrophy
Other Causes
FracturesPreexisting arthritis
TumorCervical disc disease
Heterotopic ossification Radicular and referred pain
INTRODUCTION
Gresham:Most of stroke patient
are elderly
• Referred pain of cardiac origin ??
Griffin
•Medical history•Thorough diagnostic examination
If Negative: Consider less
common causes
CASE REPORT
•Osteoporosis (+)•Localized colon cancer & Elective cholecystectomy•Brain CT Scan: bilateral calcification in the basal ganglia•ECG: normal left ventricular function•MRI: ischemic leukoencephalopathy with scattered lacunar infarctions on the left side left internal capsule white matter
89-year-old woman
Chief Complaint:
sudden right-sided
weakness & slurred speech
CASE REPORT
Day 3 Day 5
Admission
Transferred to Rehabilitation
Unit
Spasticity Ashworth I
Sudden onset of severe right shoulder pain & mild right-sided rib pain
Shortness of breath, pleuritic pain, cough, gastrointestinal symptoms denied
Vital sign normal, Sat O2 97%Edema, tenderness, skin change (-)
Cervical ROM normal, Subluxation (-), Right glenohumeral ROM decreased with tenderness
Supporting Examination on Day 5
• questionable acromioclavicular joint separation shoulder sling discontinued (after consult to orthopedics)
Right Shoulder X-Ray
• No DVTVenous Doppler
• Negative for acute changeECG• Read negative by Radiologist reviewed right
heart border haziness start clarythromycinChest X-Ray• High ESR & RF• ANA, protein C, C3 complement & serum protein
electrophoresis normalBlood Test
CASE REPORT
Day 6 Day 7
Greenish sputum, Temp 380C, WBC 11.600
(85,9% neutrophyl) Susp Pneumonia
Medical oral expectorant, antibiotics
Chest Physiotherapy hydration, postural
percussion & drainage, incentive spyrometry
Chest X-ray: infiltrationand atelectasis medial
aspect of the right lowerlobe
Pain Resolved
Glenohumeral ROM back to
normal
Day 12
Chest X-ray on Day 7
DISCUSSION
Zuckerman & Shapiro, Totta & Beneck , Poduri
The Unlikely Diagnosis
• high ESR and rheumatoid factor, but ANA, protein C, C3 complement, and serum protein electrophoresis were negative
Inflamatory Arthritis
• Normal X-RayFracture, HO,
Calcific Tendinitis
•Spasticity, Exercise, Handling unlikely by history & physical exam•X-Ray shows no cancer•Serum electrophoresis did not suggest multiple myeloma
Extrinsic Disorder
The Unlikely Diagnosis
• Risk factor (+)• Pain location atypical (sharp &
reproducible with palpation
Cardiac Ischemia
• The patient received low dose heparin
• Doppler (-)• Anand et al algorithm moderate
risk with normal venous doppler
DVT
Less Common but Likely Diagnosis
•Occur in 30% Stroke patient•Harper & Newton absence of classic sign correlated with age (>65) & cognitive & baseline functional impairment on admission
PNEUMONIA
Referred pain from pulmonary organ
Shoulder Pain & decreased ROM resolved after pulmonary toilet & antibiotic
PROBABLE SOURCE OF PAIN
CONCLUSION
A high index of suspicion and early treatment may prevent morbidity
THANK YOU