Patient ID: R. E.

is a 43-year-old African American woman, is unaccompanied, and reliable for

history-taking.

SUBJECTIVE
Chief complaint: “Hurting shoulder”
History of Present Illness: Ms. R. E. complains that her left shoulder has been “hurting for the
past one month”. The pain started abruptly one morning, a month ago when she realized it was
“difficult to move the left arm” and attempts to move it became excruciatingly painful beyond a
certain range, but has persisted. It is aggravated by any attempts to lift the arm above the
shoulder and she relieves it with acetaminophen. She reports a 7/10 pain and some bearable pain
after relief with the analgesic
Personal and social history: Patient works at Reigns Gym as a fitness coach. She admits to
attending to many clients every day and that her job is stressful because she works with the
assistance of her husband, Tim, alone. She denies tobacco use but admits recreational marijuana
use at most twice a month, and drinking 1-2 alcoholic drinks a week with one drink per sitting on
weekends. Her work entails exercising routinely.
Past Medical/Surgical History: Ms. R. E. is Type-2 diabetic, had tonsillectomy and
adenoidectomy a year ago, and immunizations UTD.
Family History: She reports histories of Type-2 diabetes (father, 68), hypercholesterolemia
(brother, 34), and congestive heart failure (maternal grandfather, died at 70).
Medications: Amaryl 2mg PO and Tylenol (Acetaminophen) 650mg PO PRN.
Allergies: No known allergies.
Review of Systems: General – Reports painful left shoulder, denies fever, chills, weight
changes, or fatigue. HEENT: Denies headache, hearing or vision changes, or sore throat.
Cardiovascular: Denies heart disease or palpitations. Respiratory: Denies sinus congestion,
difficulty breathing, chest pains, or cough. Musculoskeletal: Denies other joint or muscle pain.
Gastrointestinal – Denies nausea or vomiting, denies diarrhea, melena or constipation.
Genitourinary: Denies dysuria or urinary frequency. Neurological: Denies anxiety, seizures,
syncope, or disorientation. Integumentary: Denies pruritus or rashes. Allergic/Immunological:
Denies any allergic experience. Psychiatric: Denies mood changes, depression, or anxiety.
Hematologic/Lymphatic: Denies enlarged lymph nodes, easy bruising or bleeding. Endocrine:
Denies polyphagia, polydipsia, or heat/cold intolerance.

OBJECTIVE
Vitals: T-98.3, P-72, R-33, BP-122/85, PO2-97%, Ht-5’7, Wt-71kg (155 lbs), BMI-24.8.
General: 43-year-old African American woman, with pained expression but alert, oriented, and
follows commands. Musculoskeletal: no deformities in neck and spine, no signs of inflammation,
and spine curvature normal, gait normal, shoulders without erythema deformity, or ecchymosis.
Left shoulder limited abduction, tender on palpation, and unable to perform strength test. Right
shoulder full ROM, and full ROM in elbows, knees, hips, ankles, hands, with no swelling or
tenderness. Reflexes 2/4 and radial and dorsalis pulses 2+. Left shoulder MRI shows thickening
of joint capsule, abnormal soft tissue thickening and encasing biceps anchor. Neck: No
lymphadenopathy or masses. Abdomen: Soft, non-distended, no palpable masses, non-tender.
Cardiovascular: No murmurs, rubs, or precordial movement; pulses equal bilaterally (radial and
dorsalis), capillary refill 1 second. Neuro: Adequate attention span, appropriate judgment, and
appropriate vocabulary but speech labored due to intermittent pain, no facial neurological
deficits. Respiratory: Lungs clear to auscultation bilaterally, no crackles, shortness of breath, or
wheezing, No accessory muscle use. Extremities: No edema or tenderness. Skin: Warm, no
lesions or rashes.

ASSESSMENT
Primary Diagnosis – Adhesive capsulitis due to immobility of left shoulder and intolerance to
activity and to attempt extreme joint movements due to extreme pain (Zhu et al., 2019). MRI
supports diagnosis due to tissue thickening, limited capsular distention, synovial hypertrophy,
and scar tissue formation. Adhesive capsulitis of the shoulder exhibits limited active or passive
mobility of shoulder (glenohumeral) joint and is associated with extreme pain (Zappia et al.,
2016).
Differentials
Ankylosing spondylitis - due to stiffness of shoulder joint, tissue thickening, and pain.
Ankylosing spondylitis is a form of arthritis associated with inflammation of joints, ligaments,
and spine and usually presents with mild lower back pain and affects the spine but can affect the
shoulder and other joints (NIAMS, 2020; Zhu et al., 2019). Therefore, observed normal spine,
gait, and lack of inflammation signs rule out ankylosing spondylitis.
Biceps rapture (tendinopathy) – due to pain and tenderness in the shoulder joint area and
occupation in repetitive shoulder joint use. Biceps tendinopathy is a pain and tenderness of area
around biceps tendon, 90-97%% of the time affecting proximal tendon, because of susceptibility
to repetitive lifting activity injury (Wieting, 2020). The pain associated with biceps rapture
however has a rapid onset localized to the location of the tendon rather than all over the joint and
does not limit range of motion due to stiffness as with adhesive capsulitis.
Referred pain: Most disease conditions present as pain referred to the shoulder such as lung
infections, cervical spine or a malignancy like Pancost tumor (Mezian et al., 2021).

PLAN
Pharmacotherapy: Continue on Amaryl 2mg PO for her diabetes and Tylenol 650mg PO PRN
for pain management.
Physiotherapy: Physiotherapy should be the first therapeutic approach to treatment and
prevention of further stiffness and to prevent further limitation of motion (Zappia et al., 2016).
Other options are mobilization of glenohumeral joint under sedation. Using the protocol
proposed by Deepak Sharan and Joshua Rajkumar (2017) provides guidance on benefits of
exercise as treatment and effectiveness of motivation during patient education.
Diagnostics: Request arthrography to confirm diagnosis and rule out others based on observation
of tissue and joint appearance.
Health Education and Promotion: Ms. R. E. should be educated on occupational risks of her
job and how to limit injury due to continuous lifting. She should be encouraged to take up
therapy services that can help in health promotion and patient wellness (Kisner et al., 2017). She
should also be educated on ankylosing spondilytis and why it may be the condition she is facing.
 References
Kisner, C., Colby, L. A., & Borstad, J. (2017). Therapeutic exercise: foundations and techniques.
Fa Davis.
Mezian, K., Coffey, R., & Chang, K. V. (2021). Frozen shoulder. In StatPearls [Internet].
StatPearls Publishing.
National Institute of Arthritis and Musculoskeletal and Skin Disease (NIAMS). (2020).
Ankylosing spondylitis, NIH, https://www.niams.nih.gov/health-topics/ankylosing-
spondylitis
Sharan, D., & S Rajkumar, J. (2017). Physiotherapy for ankylosing spondylitis: systematic
review and a proposed rehabilitation protocol. Current Rheumatology Reviews, 13(2),
121-125.
Wieting, J. M. (2020). Biceps rupture. Medscape,
https://emedicine.medscape.com/article/327119-overview
Zappia, M., Di Pietto, F., Aliprandi, A., Pozza, S., De Petro, P., Muda, A., & Sconfienza, L. M.
(2016). Multimodal imaging of adhesive capsulitis of the shoulder: Insights into imaging,
7(3), 365-371.
Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., Qiu, G., Cao, X., & Weng, X.
(2019). Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone research, 7,
22. https://doi.org/10.1038/s41413-019-0057-8