Identifying Data:
Full Name: Mrs. B.D
Address: Elmhurst, NY
Date of Birth: 09/29/1952
Date & Time: 11/16/2021
Source of Information: Self
Reliability: Reliable
Source of Referral: Orthopedist
Chief Complaint: “My right shoulder hurts” x 1 year.
History of Present Illness:
A 69-year-old female with PMH of hypertension, diabetes, and hypercholesterolemia presented to Preadmission Testing for her right total shoulder replacement scheduled on 12/02/2021. The patient complained of right shoulder pain for the past year. The pain started after she tripped and fell on her right side at work a year ago, and it had not gotten better since then. The patient described the pain as dull, constant, radiating down the anterior surface of her arm at an intensity of 2/10. The intensity increased to 10/10 when she raised her right arm. The pain is alleviated by rest and exacerbated by any movements of the right shoulder. The patient tried physical therapy in the past year but it didn’t help. The patient denied syncope or loss of consciousness before/after the fall. She denied other muscle/joint pain, sensory changes, fever, chills, chest pain, and SOB.
Past Medical History:
COVID in March, 2020
Varicose vein x 5 years
Diabetes x 10 years
Hypertension x 20 years
Hypercholesterolemia x 20 years
Screening Test – Fecal occult blood test 2018, normal
Immunization up to date
Past Surgical History:
No past surgical history
Medications:
Lipitor (Atorvastatin) 10 mg PO once daily
Cozaar (Losartan) 50 mg PO once daily
Biguanides (Metformin) 500mg PO BID
Allergies
NKDA
Denied food and environmental allergies
Family History:
Mother – Deceased at age 45, heart attack.
Father – Deceased at age 69, heart attack.
Brother – 58, alive, PMH of diabetes, hypertension, and hypercholesterolemia
Daughter – 48, alive and well
Son – 44, alive and well
Social History
Mrs. B.D. is a married female living with her husband
Habits – Denies alcohol and tobacco use. Denies history of substance abuse and illicit substance use. She drinks a cup of coffee occasionally.
Travel – Denies recent travel.
Occupation – Hotel Housekeeper
Sexual Hx – Not sexually active. Menopause at age 48. Denies history of sexually transmitted disease.
Review of System:
General – Denied loss of appetite, generalized fatigue, recent weight loss or gain, fever, and night sweats
Skin – Denied moles/rashes, change of skin texture, pigmentation, excess dryness or sweating, open wound, itchiness.
Head – Denied headache, light-headedness, recent head trauma, sinus pain or nasal congestion.
Eyes – Patient is presbyopic, wears reading glasses. Last eye exam 5 years ago. Denied other visual disturbances, photophobia, redness, discharge and tearing.
Ears – Denied tinnitus, deafness, pain, discharge, or use of hearing aids.
Nose – Denied discharge, obstruction, epistaxis, loss of smell, recent trauma to nose, itchiness.
Mouth/throat – Patient has removeable dentures. Denied sore throat, bleeding gum, mouth ulcers, voice change.
Breast – Denied pain, and nipple discharge.
Pulmonary system – Denied cough, sputum, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, hemoptysis and cyanosis.
Cardiovascular system – Hypercholesterolemia. Denied heart murmur, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal system – Denied Nausea, loss of appetite, abdominal pain, and watery diarrhea. Denied vomiting, rectal bleeding, dysphagia, hemorrhoids and jaundice.
Genitourinary system –Denied urinary frequency, urgency, oliguria and incontinence. Monogamous, not sexually active. Denies history of STI.
Menstrual/Obstetrical – G2 P2 (NSVD X2). Menarche age 12. Menopause at age 48. Denied abnormal vaginal discharge, itching, pain of vagina.
Nervous system – Denied seizure, weakness, sensory disturbances, memory change, and ataxia.
Musculoskeletal system – Right shoulder pain. Bilateral varicose veins. Denied back pain.
Hematological system – Denied easy bruising or bleeding, anemia, blood transfusion, lymph node enlargement.
Endocrine system –Denied polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating or hirsutism.
Psychiatric –Denied history of depression, anxiety, feeling of helplessness, hopelessness, lack of interest in activity, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
Temp: 98.6 F
BP: 110/70 sitting up
120/80 supine
Pulse: 80, regular
RR: 18/min, unlabored
O2: 98% room air
Ht: 5’2’’
Wt: 140lb
BMI: 25.6
General: Average-built female in gown, sitting supine with her left hand supporting her right elbow. Patient was not in acute distress and is alert and oriented.
Skin – intact, feet are cold to palpate. No pitting edema. No jaundice.
Hair – average quantity and distribution
Nails – no clubbing, capillary refill <2 seconds
Head – normocephalic, atraumatic, non-tender to palpation throughout
Ear – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex. Weber midline/Rinne reveals AC>BC in both ears.
Sinuses – Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses
Eyes – Symmetrical OU, No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Visual acuity corrected – 20/20 OS, 20/20 OD, 20/20 OU
Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Chest –Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart – Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
JVP is 3cm above the sternal angle with the head of bed at 30 degrees.
Motor/Cerebellar – Limited active and passive ROM of right shoulder due to pain. Right arm strength 3/5. Other extremities strength 5/5. Full active/passive ROM of other joints without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Unable hold arm at 90 degree to perform Rhomerg and pronator drift.
Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis
Peripheral Vascular – Varicose veins bilaterally. Feet are cold to palpation. The extremities are normal in color and size. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or edema noted bilaterally. No ulcerations noted.
Musculoskeletal – Limited range of motion in right shoulder upon adduction, abduction, internal and external rotation due to pain. FROM of left shoulder and lower extremities bilaterally. No soft tissue swelling/ erythema /ecchymosis/ atrophy/ or deformities in bilateral upper and lower extremities. Non-tender to palpation/ no crepitus noted throughout. No evidence of spinal deformities.
Lips – Pink, moist, no cyanosis or lesions.
Mucosa – Pink, well hydrated, No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions, masses, scars.
Teeth – Good dentition. No obvious dental caries noted.
Gingivae – Pink, moist. No hyperplasia, masses, lesions, erythema or discharge.
Tongue – Pink, well papillated. No masses, lesions or deviation.
Oropharynx – Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions.
Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills. Bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender. No palpable masses, no thyromegaly, no bruits noted
Abdomen – Flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness
Genitalia – External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal – Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Breast – Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary node palpable
Sensory – Cranial nerves I – XII intact. Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally
Reflexes – 2+ throughout, negative Babinski, no clonus appreciated
Meningeal Signs – No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
Differential diagnoses:
#1. Shoulder osteoarthritis: Patient’s age and previous history of injury put her at higher risk of osteoarthritis of the shoulder. Limited range of motion at the injured shoulder, constant pain, and minimal improvement with physical therapy are consistent with osteoarthritis.
#2. Rotator cuff injury: Patient’s history of falling on her right side, limited ROM of right shoulder, and pain with passive and active shoulder movement suggest rotator cuff injury. However, the patient denied pain on palpation, making this diagnosis less likely.
#3. Tendon rupture: Tendon rupture could be a result of her fall. It can cause pain and decreased range of motion at the affected joint.
#4. Shoulder bursitis: Shoulder bursitis causes shoulder pain and stiffness. Falling on her right side could cause injury to the shoulder and lead to tendinitis.
#5. Rheumatoid arthritis: The patient’s age put her at increased risk for rheumatoid arthritis. Limited range of motion and pain with joint movement is consistent with rheumatoid arthritis. However, she didn’t report any stiffness with other joints. There is no swelling for inflammation of the joint throughout.
Assessment:
A 69-year-old female with PMH of hypertension, diabetes, and hypercholesterolemia presented to Preadmission Testing for her right total shoulder replacement scheduled on 12/02/2021. The history of fall, the long duration of pain, and the symptom of pain during movement is most consistent with osteoarthritis of the shoulder.
Plan:
- Pain control: Acetaminophen 650mg every 6 hours as needed
- Activity: Perform range-of-motion exercises as tolerated
- Right total shoulder replacement on 12/02/2021
