Shoulder Pain
HISTORY:
shoulder pain for
Onset: , following
Location:
Radiation:
Severity: , / 10
Type:
Pattern: ,
Worsening factors:
Treatments tried: ,
Occupation:
Dominant hand:
Other elements:
EXAM:
Shoulder:
- Inspection:
- Palpation: on
- Range of motion:
- Flexion:
- Neurovascular: , distal pulses , cap refill , sensation , distal strength /5
- Special tests:
ASSESSMENT:
DDx:
PLAN:
- Shoulder X-ray
- Ultrasound of the shoulder
- MRI of the shoulder
- Remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
- Steroid injection
- for
- Referral to orthopedic surgeon
- Follow-up in
- Return if pain worsens or if symptoms do not improve with treatment