maria margarita a. mejia november 18, 2010 1. identifying data rn, 63 y/o filipino female,...
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Maria Margarita A. MejiaNovember 18, 2010
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Identifying DataRN, 63 y/o Filipino female, right-handedRoman CatholicFrom CaviteInformants
Patient: Good reliabilityDaughter: Good reliability
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Chief ComplaintLeft shoulder painLimited movement of the shoulder joint
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History of Present Illness10 days PTC
Experienced pain (10/10) and immobilization of the left shoulder while laundering foam mattress
Movement before injury: tossing the mattress over
Radiation of pain and immobilization to the forearm
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History of Present Illness10 days PTC
No popping sound or dislocations were notedAssociated with the following symptoms:
SwellingFever for 2 days took paracetamolDifficulty of sleeping for 3-4 days
No consult done
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History of Present Illness8 days PTC
• Sought consult at a private clinic – prescribed the following medications:– Paracetamol + Vitamin B (1 tab TID) did not
afford pain relief– Amlodipine, 5mg (once a day)– Roxithromycin (1 tab, BID)
• Advised x-ray of the shoulder – read as posterior dislocation of the right shoulder joint
• Self-medicated with Diclofenac (Voltaren) – (+) pain relief
History of Present IllnessOn the day of consult
• Persistence of symptoms prompted consult at a private clinic where she was prescribed Celecoxib 200mg tablet, twice a day
• Referred to our institution for consult
Other HistoryPertinent ROS Functional HistoryNo Fever, weight gain or
weight loss, easy fatigability
No Headache, seizures, blurring of vision, ear problems
No Dyspnea, cough, coldsNo Palpitations, chest painNo Nausea, vomitingNo Dysuria, frequency(+) stomach irritation
Unilateral hand useDifficulty bathing and
doing household choresAble to eat and write
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Other HistoryPast Medical History Personal-Social History
Cardiac hypertrophyHypertension (?)
RetiredMarriedLiving with her daughter
in Cavite
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Vitals: BP 110/70, 36.4oC (afebrile), RR 20, HR 78
• General: conscious, coherent, alert, not in cardiorespiratory distress
• HEENT: Anicteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathies
• Chest: Symmetric chest expansion, no retractions , clear breath sounds
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Physical Exam
Physical ExamCardiovascular: Adynamic precordium,
distinct heart sounds, regular cardiac rate and rhythm
Abdomen: Flat, no masses palpated, normoactive bowel sounds
Digital rectal exam: not done
Physical ExaminationExtremities: Full and equal pulses, fair skin
color, good skin turgor; swollen and tender left shoulder
DTR:UER:++UEL: not testedLE: ++ (bilateral)
Sensory: intact in all levelsROM: restricted for the left shoulder joint(+) drop-arm test
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Manual Muscle Testing(Upper Extremity)
Right Left
Shoulder abduction 5/5 2/5
Shoulder adduction 5/5 2/5
Shoulder flexion 5/5 2/5
Shoulder extension 5/5 2/5
Elbow flexion 5/5 2/5
Elbow extension 5/5 2/5
Wrist flexion 5/5 4/5
Wrist extension 5/5 4/5
Manual Muscle Testing (Lower Extremity)
Right Left
Hip flexors 5/5 5/5
Knee extensors 5/5 5/5
Ankle dorsiflexors 5/5 5/5
Long toe extensors 5/5 5/5
Ankle plantar flexors 5/5 5/5
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Neurological ExaminationCN I: not doneCN II, III: pupils 2-
3mm, equally brisk reaction to light
CN III, IV, VI: full EOMs
CN V: intact V1, V2, V3; good masseter muscle tone;
CN VII: no facial asymmetry
CN VIII: gross hearing intact
CN IX, X: can swallow
CN XI: good shoulder shrug
CN XII: tongue midline
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Primary Impression• Adhesive capsulitis (frozen shoulder) rule out
Shoulder Impingement Syndrome
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Salient Features• 63 year old, female• Acute onset• First episode• Acquired injury while flipping heavy object • Pain and inflammation on the left shoulder• Accompanied by fever and difficulty of
sleeping• Unable to abduct left shoulder joint
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Shoulder Impingement Syndrome Salient Features +/-63 year old, female +Acute onset -First episode +Acquired injury while flipping heavy object
+/-
Pain and inflammation on the left shoulder
+
Accompanied by fever and difficulty of sleeping
+
Unable to abduct shoulder joint +
Shoulder Joint DislocationSalient Features +/-63 year old, female +/-Acute onset +/-First episode -Acquired injury while flipping heavy object
+/-
Pain and inflammation on the left shoulder
+/-
Accompanied by fever and difficulty of sleeping
-
Unable to abduct shoulder joint +/-
OsteoarthritisSalient Features +/-63 year old, female +Acute onset -First episode -Acquired injury while flipping heavy object
+/-
Pain and inflammation on the left shoulder
+/-
Accompanied by fever and difficulty of sleeping
-
Unable to abduct shoulder joint +/-
Adhesive Capsulitis“Frozen Shoulder” – 1934 by CodmanAdhesive capsulitis – 1946 by NeviaserCharacteristics:
PainRestriction of active and passive movement of
glenohumeral joint / global loss of functionUsually with normal radiologic findingsCommon in females, 40-60 y/o
Adhesive Capsulitis• Associated with DM, hyperthyroidism,
ishemic heart disease, inflammatory arthritis and cervical spondylosis
• Glenohumeral joint synovial capsule is often involved in this disease process
• ROM loss disease in structures outside the synovial capsule glenohumeral joint (e.g. coracohumeral ligament, soft tissues in the rotator interval, the subscapularis muscle, and the subacromial bursae)
Adhesive CapsulitisActive process of
hyperplastic fibroplasia and excessive type III collagen secretion soft-tissue contractures other structures
Adhesive Capsulitis
Synovial capsule of glenohumeral joint is involved
• Stages:– “Freezing phase” –
pain; 3 to 6 months– “Frozen phase” –
progressive stiffness and movement restriction; 3 to 18 months
– “Thawing phase” – resolution; slow recovery of motion
Impingement SyndromeMechanical impingement of the rotator
cuff tendonUsually occurs when the shoulder is
placed in the forward-flexed and internally rotated position
Common in older personsRotator cuff disease, GH joint
degenerative diseasePain and positioning of the patient
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Laboratory TestsLaboratory Test RationaleCBC with differential count
Baseline values; r/o infections, inflammation
ESR Baseline; r/o rheumatoid conditions
Blood Glucose r/o hypoglycemia or DMThyroid function tests r/o thyroid dysfunction
Special TestsImpingement test: Inject 10 mL of 1%
lidocaine solution into the subacromial space. Repeat testing for an impingement sign. Elimination or significant reduction of pain constitutes a positive impingement test.
Drop arm test: The patient places the arm in maximum elevation in the scapular plane and then lowers it slowly (the test can be repeated following subacromial injection of lidocaine). Sudden dropping of the arm suggests a rotator cuff tear.
Imaging StudiesStandard radiographic studies (4
views)MRI – imaging study of choiceArthrography – to assess integrity of
the joint
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ManagementGoals:
Pain relief - NSAIDsRestore motion
Self-limited process but disabling pressing problem
Aggressive physical therapy to regain motionCorticosteroid injections for anti-
inflammation during the “freezing phase”Manual manipulation – last resort for
treatment
Maria Margarita A. MejiaNovember 18, 2010
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