Question

Mrs. Johnson is a 73 y.o. female who presents to your office with right shoulder pain. Her and her husband just moved to the area a few months ago, and you have only seen her once for a sinus infection. Today she states that she is having increasing right shoulder pain over the past couple of weeks. She explains that her shoulders have “always bothered” her because she worked in a factory moving boxes for years. She states that she uses naproxen, “prescription strength” and that usually does the trick when her arthritis flares up, but she is out and would like a refill. On exam, you note that her right shoulder is tender to palpate, and she has limited motion. She smells of BenGay but otherwise, she seems healthy. The area is edematous and when asked she does agree that her arm seems swollen. She denies any falls but remembers that she lost her balance and fell backward into her recliner a few days ago “kind of hard” but she caught herself when she grabbed for the coffee table. Otherwise, she does not recall any injuries. You decide to send Mrs. Johnson for an x-ray and she is in the waiting room until you get the results back. The following radiograph is what is sent to you via teleradiology.

1. What would be your primary choice for an underlying diagnosis for Mrs. Johnson, and why?

2. What past pertinent information related to a pathological fracture and your second suspected diagnosis would you like to ask Mrs. Johnson?

3. Are there any additional tests, radiological studies, etc. that you would order for Mrs. Johnson?

4. Will you refer this patient, and if so, to whom?

Answer 1

1.The underlying diagnosis which is mentioned here is the pathological fracture This has been made as a primary choice because of the following reasons like increasing age or elderly client, increasing pain, swollen or edematous arms, tender shoulder ,work history suggests for this diagnosis .

2.The work history of the patient moving boxes in her job is related to pathological fracture .The second suspected diagnosis which can be made here is frozen shoulder because of her limited mobility ,pain in shoulder and age.

3.The additional test which can be ordered are

• CT scan or MRI scan to rule out any abnormal growth, lesion or tumor
• CBC to get basic counts
• Serum calcium levels because deficiency of this can cause easy fracture due to bone illness
• Serum alkaline phosphatase level
• Serum electrophoresis
• CEA
• ESR
• urine analysis

4.This patient has to be referred to an orthopedecian as the problem is related to Musculoskeletal system .