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Mrs. Ryan, a 57 year old woman with a 10 year history of type II diabetes mellitus, requests your evaluation of shoulder and upper arm pain.
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Left shoulder area and lateral upper arm aching began about 2
months ago, following several days of wall-papering activity.
There was no history of trauma. Subsequently, she experienced
pain when attempting to reach over her head, place her arm in a
sleeve or fasten her bra. She also experienced pain when lying
on the left shoulder at night. The patient denied neck, chest or
abdominal pain and had no fevers or other systemic symptoms. She
experienced no previous shoulder pain or other major
musculoskeletal problems.
The patient treated herself with ibuprofen and a sling for pain relief. Over the ensuing weeks she experienced less acute pain with motion, but lost the ability to lift the arm fully over the head. She could not use the left arm to wash her hair and she could not reach behind to scratch her back. Past history was notable only for longstanding type II diabetes mellitus. She has had no history of end organ involvement from her diabetes. Medications include glyburide 5 mg daily and a multivitamin daily. No allergies were reported. |
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Focused examination
Vital Signs: Temperature 37 C, HR 72, BP 130/76, RR 16 General Appearance - in no distress at rest, no evidence for joint deformity Neck - normal in appearance with only mild upper back pain on motion Left Shoulder - Appearance - no swelling, deformity or atrophy when compared to the left shoulder. Palpation - no local tenderness to palpation over the subacromial area, acromio- clavicular joint, or biceps tendon Range of motion - marked limitation of both active and passive motion, with pain present when patient neared the end of that motion Resisted motion (isometric resistance against examiner) - resisted abduction and external rotation of the shoulder both produced only minor discomfort Right Shoulder - full active motion without pain Neurologic Exam - no sensory, motor or
reflex abnormalities in the right arm, compared with the left
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The
nature of the problem was discussed with the patient. Ibuprofen
600 mg three times daily with meals and a home exercise regimen
were prescribed. The patient was diligent with her program.
On return for a follow-up visit two weeks
later, she reported somewhat less pain and greater ease in
placing her arm in a sleeve and reaching over her head. Range of
motion had improved, but was still limited. |
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