Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is called Bob Builder, a 41-year-old gentleman presenting with shoulder stiffness. Please take a history and perform an appropriate examination.
Patient History:
Bob Builder, a 41-year-old gentleman, construction worker.
A few weeks ago, your left shoulder started becoming stiffer than usual, affecting movements in all directions; stretching exercises help with stiffness slightly, but stiffness is the same throughout the day. This is causing problems for you as you now need help with overhead activities and putting on your clothes. You feel like your left shoulder can no longer move as it used to with a limited range of motions.
Six months ago, you had a gradual worsening, constant left shoulder pain, which is often worse at night affecting your sleep- however, this is slowly getting better, so you are not too concerned, and you have a high pain tolerance. You describe the pain as a dull ache - rating it 2/10 currently. No radiation. No previous recent injury or known trigger. You tried many painkillers, such as paracetamol, with only minimal effects.
Idea, Concern, Expectation:
You have no idea what is going on. You work in construction, so this may be related. You had a few injuries towards your left shoulder in the past but nothing major. You are concerned as your work often involves very active use of your left shoulder, and you now have problems at work due to stiffness. You would like to see if you can have a sick note for this.
Past Medical History:
Type 2 diabetes, hypothyroidism
Previous left shoulder rotator cuff injury, which was treated conservatively three years ago.
No previous surgical history
Drug History:
Metformin, levothyroxine.
Allergic to fish - Rash.
Family History:
Mother has osteoarthritis affecting both hips.
Social History:
Work as a builder
Non-smoker
Drink around 3-5 units a week over a weekend.
Live with wife in a flat
Examination Findings:
Left shoulder stiffness on both active and passive movement in all directions with limited range of motions. However, external rotation is most affected. The whole shoulder joint is mildly tender to palpation.
Positive coracoid pain test - tenderness with direct pressure on the coracoid
Positive shoulder shrug test - inability to abduct arm to 90degree in the plan of body and to hold the position.
No tenderness at acromioclavicular joint. No painful arc on shoulder abduction.
Negative for other manoeuvres or shoulder tests.
Differentials:
Adhesive capsulitis (pain phase transitioning to stiff phase)
Supraspinatus tendinopathy
Acromioclavicular joint arthritis
Glenohumeral joint arthritis
Things to consider: septic arthritis, inflammatory arthritis, malignancy e.g. osteosarcoma, bony mets, fractures, shoulder dislocation, rotator cuff injury...etc.
Investigations:
Clinical diagnosis
Consider routine bloods if indicated to rule out other pathologies
Consider shoulder XR shoulder e.g. may show signs of arthritis
Consider ultrasound, CT, MRI (may show thickened joint capsule in adhesive capsulitis)
Management: