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-=-=-=-=-=> SHOULDER PAIN Doorway information about patient The patient is a 56 - year - old man who comes to the clinic due to shoulder pain. Vital signs . Temperature : 37’C . Blood pressure : 130/80 mmHg . Pulses : 80 / min . Respirations : 12/min Approach to the patient Shoulder pain can be categorized based on the following factors: . Acute (<2weeks) or chronic . Traumatic or atraumatic . Intrinsic or extrinsic , include radicular and referred pain . Location (eg, anterior, superior , diffuse) The clinical history in shoulder disorders is often fairly straightforward , but a though examination amy require an extended time . Physical examination for should pain , as for many orthopedic disorders , benefits form a variety of standardize , validated maneuvers (eg , painful arc test , Neer impingements test ). Be sure to allow adequate time for examination and an appropriate wrap-pup discussion. Differential diagnosis Common causes of shoulder pain 1 Rotator cuff impingement or tendinopathy . Pain with abduction , external rotation . Subacromial tendernes . Normal range of motion with positive -impingement tests-(eg, Neer, Hawkins) 2 Rotator cuff tear . Similar to rotator cuff tendinopathy . Weakness with external rotation . Age>40 3 Adhesive capsulitis (frozen shoulder) . Decreased passive &active range of motion . More stiffness than pain 4 Biceps tendionpathy/rupture . Anterior shoulder pain . Pain with lifting , carrying , or overhead reaching . Weakness less common 5 Glenohumeral osteoarthritis .Uncommon & usually cause by trauma . Gradual onset of anterior or deep shoulder pain . Decreased active & passive abduction & external rotation Most pasting with shoulder pain have an intrinsic musculoskeletal disorder of the shoulder . however , features suggesting referred pain form the internal organs (eg, heart , gallbladder) include pain not related to motion or position , nomusculoskeketal system (eg, cough , nausea), vague or diffuse location, and significant medical risk factors(eg , heavy smoking) The most common cause of shoulder pain in a primary care setting is -subacromial impingement syndrome- , group of disorder (eg, subacromial bursitis , rotator cuff tendinitis , tedinitos of the long head of biceps),characterized by worsening of pain with lifting the arm overhead or lying on the affected side. HHISTROY AND PHYSCIAL EXAM History History of present illness . Tell me about your pain. . When did this pain begin? . Did you fall or experience any trauma? . Where do you feel it the worst ? Dose the pain move anywhere? . How severe is the pain ? . What makes it better or worse? . Is it constant or intermittent? . Do you have numbness or tingling in your arms or hands? . Have you noticed redness or swelling in the shoulder? . Do you have pain in any other part of your body? . Do you have nay otters symptoms?(eg, cough, shortness of breath)? . Have you taken medications of the pain? If so , did they help? . How is this affecting your daily activities? Past medical history . Have you ever had a similar problem? . When was it diagnosed & treated ? . have you been diagnosed with other medical conditions (eg,diabetes , heart disease) Social history . What kind of work do you do? . Do you smoke? At what age did you stare & how much do you smoke ? . Do you drink alcohol ? how much & how often? . Have you ever used recreational drugs? As your examine the shoulder , try to visualized the underlying musculoskeletal anatomy. Additional information on examination of the shoulder can be found in the physical Examination section. physical examination Musculoskeletal . Inspection for swelling , deformity , or redness. . Palpation for warmth or tenderness. . Chance range of motion (passive & active), including flexion , extension , abduction & adduction . Perform specific maneuvers as appropriate. . Examine both shoulder for comparison . Examine the cervical spine , sternoclavicular joint & elbow Skin . Examine ofr rash (eg, Herpes zoster). Neurologic . Check reflexes. . Check motor fiction & gross sensory examination in hand & arm. Closing the encounter In the warp-up discuss with the patient , explain your differential diagnosis and the significance of abnormal finding form the physical examination . Encourage the patient to discuss how the problem is affecting activities. In most musculoskeletal conditions , diagnosis and management is heavily dependent on the acuity and course over time . Patient with acute trauma or with prolonged symptoms that have not improved as expected warrant a more aggressive evaluation , whereas patient with subacute symptoms that are slowly improving may benefit form symptomatic management and close follow-up . -=-=-=-=-=>
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