Mrs. Freeze

1. Mrs. Freeze Maria Margarita A. Mejia November 18, 2010

2. Identifying Data • RN, 63 y/o • Filipino female, right-handed • Roman Catholic • From Cavite • Informants • Patient: Good reliability • Daughter: Good reliability

3. Chief Complaint • Left shoulder pain • Limited movement of the shoulder joint

4. History of Present Illness 10 days PTC • Experienced pain (10/10) and immobilization of the left shoulder while laundering foam mattress • Movement before injury: tossing the mattress over • Radiation of pain and immobilization to the forearm

5. History of Present Illness 10 days PTC • No popping sound or dislocations were noted • Associated with the following symptoms: • Swelling • Fever for 2 days  took paracetamol • Difficulty of sleeping for 3-4 days • No consult done

6. History of Present Illness 8 days PTC • Sought consult at a private clinic – prescribed the following medications: • Paracetamol + Vitamin B (1 tab TID)  did not afford pain relief • Amlodipine, 5mg (once a day) • Roxithromycin (1 tab, BID) • Advised x-ray of the shoulder – read as posterior dislocation of the right shoulder joint • Self-medicated with Diclofenac (Voltaren) – (+) pain relief

7. History of Present Illness On the day of consult • Persistence of symptoms prompted consult at a private clinic where she was prescribed Celecoxib 200mg tablet, twice a day • Referred to our institution for consult

8. Other History Pertinent ROS Functional History • No Fever, weight gain or weight loss, easy fatigability • No Headache, seizures, blurring of vision, ear problems • No Dyspnea, cough, colds • No Palpitations, chest pain • No Nausea, vomiting • No Dysuria, frequency • (+) stomach irritation • Unilateral hand use • Difficulty bathing and doing household chores • Able to eat and write

9. Other History Past Medical History Personal-Social History • Cardiac hypertrophy • Hypertension (?) • Retired • Married • Living with her daughter in Cavite

10. Physical Exam • Vitals: BP110/70, 36.4oC (afebrile), RR 20, HR 78 • General: conscious, coherent,alert, not in cardiorespiratory distress • HEENT: Anicteric sclerae, pink palpebral conjunctiva, neck veins non-distended, no cervicolymphadenopathies • Chest: Symmetric chest expansion, no retractions , clear breath sounds

11. Physical Exam • Cardiovascular: Adynamic precordium, distinct heart sounds, regular cardiac rate and rhythm • Abdomen: Flat, no masses palpated, normoactive bowel sounds • Digital rectal exam: not done

12. Physical Examination • Extremities: Full and equal pulses, fair skin color, good skin turgor; swollen and tender left shoulder • DTR: • UER:++ • UEL: not tested • LE: ++ (bilateral) • Sensory: intact in all levels • ROM: restricted for the left shoulder joint • (+) drop-arm test

13. Manual Muscle Testing(Upper Extremity)

14. Manual Muscle Testing (Lower Extremity)

15. Neurological Examination • CN I: not done • CN II, III: pupils 2-3mm, equally brisk reaction to light • CN III, IV, VI: full EOMs • CN V: intact V1, V2, V3; good masseter muscle tone; • CN VII: no facial asymmetry • CN VIII: gross hearing intact • CN IX, X: can swallow • CN XI: good shoulder shrug • CN XII: tongue midline

16. CASE DISCUSSION

17. Primary Impression • Adhesive capsulitis (frozen shoulder) rule out Shoulder Impingement Syndrome

18. Salient Features • 63 year old, female • Acute onset • First episode • Acquired injury while flipping heavy object • Pain and inflammation on the left shoulder • Accompanied by fever and difficulty of sleeping • Unable to abduct left shoulder joint

19. Differential Diagnosis

20. Shoulder Impingement Syndrome

21. Shoulder Joint Dislocation

22. Osteoarthritis

23. Adhesive Capsulitis • “Frozen Shoulder” – 1934 by Codman • Adhesive capsulitis – 1946 by Neviaser • Characteristics: • Pain • Restriction of active and passive movement of glenohumeral joint / global loss of function • Usually with normal radiologic findings • Common in females, 40-60 y/o

24. Adhesive Capsulitis • Associated with DM, hyperthyroidism, ishemic heart disease, inflammatory arthritis and cervical spondylosis • Glenohumeral joint synovial capsule is often involved in this disease process • ROM loss  disease in structures outside the synovial capsule glenohumeral joint (e.g. coracohumeral ligament, soft tissues in the rotator interval, the subscapularis muscle, and the subacromial bursae)

25. Adhesive Capsulitis • Active process of hyperplastic fibroplasia and excessive type III collagen secretion  soft-tissue contractures other structures

26. Adhesive Capsulitis • Synovial capsule of glenohumeral joint is involved • Stages: • “Freezing phase” – pain; 3 to 6 months • “Frozen phase” – progressive stiffness and movement restriction; 3 to 18 months • “Thawing phase” – resolution; slow recovery of motion

27. Impingement Syndrome • Mechanical impingement of the rotator cuff tendon • Usually occurs when the shoulder is placed in the forward-flexed and internally rotated position • Common in older persons • Rotator cuff disease, GH joint degenerative disease • Pain and positioning of the patient

28. Laboratory Tests

29. Special Tests • Impingement test: Inject 10 mL of 1% lidocaine solution into the subacromial space. Repeat testing for an impingement sign. Elimination or significant reduction of pain constitutes a positive impingement test. • Drop arm test: The patient places the arm in maximum elevation in the scapular plane and then lowers it slowly (the test can be repeated following subacromial injection of lidocaine). Sudden dropping of the arm suggests a rotator cuff tear.

30. Imaging Studies • Standard radiographic studies (4 views) • MRI – imaging study of choice • Arthrography – to assess integrity of the joint

31. Management • Goals: • Pain relief - NSAIDs • Restore motion • Self-limited process but disabling  pressing problem • Aggressive physical therapy to regain motion • Corticosteroid injections for anti-inflammation during the “freezing phase” • Manual manipulation – last resort for treatment

32. Mrs. Freeze Maria Margarita A. Mejia November 18, 2010