GROUP 2A (TUESDAYS: 2-4 PM)

NAVARRO, Reginald Charles RAMIREZ, Hazel

PISCAWEN, Enrico SANCHEZ, Rowena Maries
TAGUILLING, Jay Adrian TURLA, Dannah Mae
GARCIA, Beatrice VILLANUEVA, Kristel
MALECDAN, Athena

DATE OF PATIENT ENCOUNTER: May 02, 2023

PRECEPTOR: Dr. Felinor William Antonio

Chief Complaint: Left shoulder pain with difficulty of movement

General Data:
Patient A.R.S. is a 43-year-old, Roman catholic, housewife born on November 29, 1979. She currently
resides at Itogon, Benguet along with her husband and two sons with ages 19 and 17 years old. She is right-
handed. The patient herself is the informant with a reliability of 95%.
History of Present Illness:
3 weeks prior to consult, the patient experienced a tingling sensation on her upper and lower left arm which
she described as “parang may tusok-tusok” which persisted until her consultation. She also complained the
feeling of losing her grip on her left hand.
1 week prior to consult, her symptoms worsened and she developed left shoulder pain which radiates to the
back of her head with difficulty of normal mobility. She rated the pain 8/10. Sometimes when she exerts
effort on her left arm and shoulder, she experiences transient abdominal pain rated at 4/10 which disappears
after resting.

Past Medical History:

Patient is currently taking maintenance medication for hypertension; 50 mg Losartan once
2023
a day.
She visited SLU Sacred Heart Hospital with a complaint of nape pain. Her blood at the time
of consultation was 160/100. Medications were given but the patient cannot recall them
2021
except for the fact that she was told to place the medicine under her tongue. She had
laboratory examinations done, both Lipid Profile and Random Blood Sugar was normal.
2020 Received her 1st and 2nd dose of COVID Vaccine.
2015 Right shoulder pain after doing household chores. She did not take any medications.
2013 She stopped wearing her glasses
Patient was diagnosed with cataract and underwent surgery. She received Intraocular Lens
1995-1996
Implant. She was advised to wear glasses, the grades were (R) 1015, and (L) 1100.
1986 According to the patient, she had a blurred vision when she was in Grade 1.

OB-GYNE History:
 LMP First day of the last menstruation was April 17 which lasted until April 23.
Duration of Menses Seven Days

Family History:
Both of the patient’s parents are deceased. The mother passed away at the age of 83 in 2020 due to old age
and possibly depression, according to the patient. The father was hypertensive and passed away at the age
of 78 in 2018.
The patient is the youngest among three siblings; all are female. The eldest is healthy and is actively
working. The second had gall bladder surgery at the age of 44.
Personal and Social History:
The patient is a non-smoker and does not consume any alcoholic beverages. She and her family have a
dietary preference of more vegetables than fish and less meat. She consumes three tumblers worth of
mineralized water every day. The tumbler is estimated to be around 250 mL. In their household, their toilet
is a gravity-flush type. Sometimes, the patient experiences difficulty falling asleep which occurs once or
twice a week.
In November 2020, her husband tested positive for COVID-19 and was advised to take a two-week
quarantine in an isolation center.
Physical Examination

General Survey Patient was awake, coherent, responsive to questions

Temperature 36.4 C°
RR 18 breaths per minute
CR 94 bpm
BP 130/90
Weight Not applicable
Height Not applicable
Skin Acyanotic, warm to touch with good skin turgor, no pitting edema
Anicteric sclerae, pink conjunctivae, no eye discharges noted; no ear
discharges, intact tympanic membrane; moist and pinkish nasal mucosa, no
nasal discharges, no sinus tenderness, nasal turbinate were not congested; Dry
HEENT lips, no scars nor lesions; Uvula is at midline =, tonsils are non-palpable and
moves with deglutition; anterior cervical lymph nodes are non-palpable; no
carotid bruit was noted
(+) gag reflex, CN 9, 10, 12 are intact
Symmetrical chest wall expansion, no retractions, resonant, equal tactile
Chest and Lungs
fremitus, vesicular breath sounds, no crackles nor wheezes
Heart Audible heart sounds, no murmurs
Flat abdomen, Everted umbilicus, tympanitic, no direct nor rebound tenderness
Abdomen
upon palpation, Normal bowel sounds
No gross deformities, pain upon palpation at the left elbow. Pain in her left
shoulder upon doing extension, abduction, inner rotation, overall rotation of the
Extremities
shoulder
Limitation of movement of the left arm (flexion, extension, inner rotation)
 Left arm: Difficulty doing the Apley scratch test
Left arm: Positive Neer’s impingement sign
Left arm: Positive Hawkin’s impingement sign
Left arm: Positive Drop-arm sign
Intact tactile sensation, Normal reflexes. Limited ROM upon doing shoulder
Neurologic Exam
extension, abduction, inner rotation, overall shoulder rotation, rotator cuff.

Review of Systems:

(-) weight loss, (-) easy fatiguability, (-) fever, (-) pain, (+) weakness in the
General
morning
Skin (-) rashes, (-) lumps, (-) sores, (-) itching, (-) dryness
HEENT:
(-) headache, (-) dizziness
Head
Eyes (-) pain, (-) burning sensation (-) eye redness (-) diplopia (+) cataracts
Ears (-) discharge (-) hearing loss
Nose (-) discharge (-) colds (-) epistaxis (-) anosmia (-) stuffiness
(-) dysphagia (-) hoarseness (-) goiter (-) neck stiffness (-) swollen glands (+)
Throat/mouth
frequent eructation
Respiratory (-) dry cough, (-) sputum, (-) dyspnea, (-) orthopnea
Cardiovascular (-) chest pain, (-) dyspnea, (-) paroxysmal nocturnal dyspnea, (-) palpitations
(-) dysphagia, (-) nausea, (-) vomiting (-) burning sensation, (-) bitter taste, (-)
GIT
loose bowel movement, (+) epigastric pain
Peripheral
(-) intermittent claudication, (-) leg cramps, (-) edema
Vascular
GUT (-) increased urinary frequency, (-) oliguria (-) dysuria (-) hematuria
Musculoskeletal (+) muscle or joint pain (-) stiffness, (+) weakness (+) limitation of motion
(-) change in speech (-) change in orientation (-) weakness (-) numbness or loss
Neurologic
of sensation (-) tingling or “pins and needles” (-) seizures (+) paresthesia
Psychiatric (-) anxiety (-) nervousness (-) tension (-) memory change

Problem List 1: Left shoulder pain with Limited range of movement

•Patient felt severe pain in her left shoulder after doing heavy laundry after
Subjective the washing machine broke down
• Pain radiating to the posterior cervical region up to the back of her head
• Limitation of movement of the left arm (flexion, extension, inner rotation)
• Left arm: Difficulty doing the Apley scratch test
Objective • Left arm: Positive Neer’s impingement sign
• Left arm: Positive Hawkin’s impingement sign
• Left arm: Positive Drop-arm sign
Assessment ROTATOR CUFF TEAR
• non-steroidal anti-inflammatory drugs and steroid injections
Plan • Take time to rest
• application of cold or heat and massage
 • Xray, MRI, or UTZ
Problem List 2: Epigastric pain
•
Patient felt severe pain in her left shoulder doing flexion pain is felt up to
her abdomen
Subjective • Relieved with rest
• No GI changes
• No diarrhea, no constipation, no GI bleeding
Objective • During palpation of the abdomen there were no tenderness
Assessment PAIN FROM THE SHOULDER RADIATING TO THE ABDOMEN
• Pain killers
• Take time to rest
Plan
• Massage
• UTZ to rule out gastric problems

Differential Diagnosis

PATIENT’S ROTATOR CUFF CERVICAL CARPAL TUNNEL

CLINICAL TEAR RADICULOP SYNDROME
MANIFESTATIONS ATHY
RISK FACTOR
43-year-old woman (+) (+) (+)
doing heavy laundry Repeating the same Factors associated with The anatomy of the
shoulder motions again increased risk include wrist, health problems
and again can stress heavy manual labor and possibly repetitive
your rotator cuff requiring the lifting of hand motions can
muscles and tendons. more than 25 pounds contribute to carpal
tunnel syndrome
HISTORY OF PRESENT ILLNESS
3 weeks prior to (-) (+) (+)
consult, the patient Tingling in the fingers Tingling in these areas
experienced a tingling often results from may indicate median
sensation on her upper compression or damage nerve involvement.
and lower left arm to the nerves Hand pain and
which she described as numbness are also
“tusok-tusok”. common symptoms of
CTS.
Complained of losing (+) (+) We may experience
her grip on her left Probably due to the tear Cervical radiculopathy weakness in the hand
hand in the rotator cuff of the is a dysfunction of a and drop objects. This
patient nerve root of the may be due to the
cervical spine. C7 and numbness in the hand
C6 cervical nerve roots or weakness of the
are the most commonly thumb's pinching
affected which can muscles, which are also
cause hand weakness controlled by the
median nerve.
1 week prior to consult, (+) (+) (-)
symptoms worsened
 and developed left Rotator cuff tear Commonly affected
shoulder pain which contributed to the nerve is C7 nerve
radiates to the back of progressive shoulder which is intercorrelated
her head with difficulty pain of the patient to our shoulder which
of normal mobility, contributes to the
shoulder pain was 8/10 patients’ shoulder pain
Sometimes when she (-) (+/-) (+/-)
exerts effort on her left Maybe due to a referred Due to the median
arm and shoulder, she pain by the nerves nerve compression,
experiences transient hand weakness is a
abdominal pain rated at common symptom.
4/10 which disappears Shoulder not usually
after resting. affected. Abdomen not
usually affected
PAST MEDICAL HISTORY
In 2015, she (+) (+) (+)
experienced right Progressive tear to the Can contribute to Repetitive motions can
shoulder pain after rotator cuff pinched nerve in the contribute to carpal
doing household neck due to heavy tunnel syndrome
chores. She did not take manual labor
any medications.
In 2021, She visited (+) (+) (-)
SLU Sacred Heart Nape pain probably due Nape pain is a common
Hospital with a to referred pain from symptom of cervical
complaint of nape pain. the shoulder. radiculopathy.
Her blood at the time of Hypertension not Hypertension not
consultation was associated associated.
160/100.
In 2023, Patient is (+) (-) (-)
currently taking Based on some studies,
maintenance hypertension increases
medication for the risk of having a
hypertension; 50 mg rotator cuff tear
Losartan once a day.
PHYSICAL EXAMINATION
Pain in her left shoulder (+) (+) (-)
upon doing extension, Probably due to the tear Shoulder affected
abduction, inner in the rotator cuff of the probably due to the
rotation, overall patient affected nerves
rotation of the
shoulder
Limited ROM upon (+) (+) (-)
doing shoulder Probably due to the tear Shoulder affected
extension, abduction, in the rotator cuff of the probably due to the
inner rotation, overall patient affected nerves
shoulder rotation,
rotator cuff.
Left arm: Difficulty (+) (+) (-)
doing the Apley scratch Loss of range of motion Shoulder affected
test Positive result: rotator probably due to the
cuff problem affected nerves
 Left arm: Positive (+) (+) (-)
Neer’s impingement Positive result: Shoulder affected
sign Subacromial probably due to the
impingement which affected nerves
refers to the
inflammation and
irritation of the
shoulder tendons
(rotator cuff)

Left arm: Positive (+) (+) (-)

Hawkin’s impingement Positive result: Shoulder affected
sign Supraspinatus tendon probably due to the
impingement which affected nerves
means the shoulder
tendons (rotator cuff)
is torn or swollen
Left arm: Positive (+) (+) (-)
Drop-arm sign Positive result: Rotator Shoulder affected
cuff tear probably due to the
affected nerves

Clinicopathological Correlation