Shoulder Trauma
Age: years old
Gender:
HISTORY:
Presents with a shoulder pain following an injury ago
Mechanism of injury:
Location is
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Dominant hand:
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , ,
EXAM:
Shoulder:
Inspection:
Palpation: on
Range of motion:
- Flexion:
- Extension:
- Abduction:
- Adduction:
- Int rotation:
- Ext rotation:
Strength: , except on
Neurovascular: , distal pulses , cap refill sec, sensation
Special tests:
- Neer sign:
- Hawkins:
- O'Brien test:
- Jobe test (empty can):
- Yocum test:
- Cross-body adduction:
- Sulcus sign:
- Apprehension test:
- Drop arm test:
- Speed's test:
ASSESSMENT:
DDx: shoulder strain, shoulder dislocation, rotator cuff tear, AC joint injury, labral tear, rotator cuff tendinopathy, shoulder impingement syndrome, subacromial bursitis, proximal biceps tendon rupture, referred pain from cervical injury, brachial plexus injury, thoracic outlet syndrome, clavicle fracture, humeral head fracture, referred pain from liver tear, referred pain from spleen tear
PLAN:
Investigations:
- Shoulder X-ray
- Ultrasound of the shoulder
- MRI of the shoulder
Treatments:
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
- Steroid injection
- for
Further care:
- Referral to orthopedic surgeon
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Shoulder: ASSESSMENT: PLAN: