Meenakshi Aggarwal MD PGY2 Family Medicine AAFP Journal Review March 20th, 2008

1. Meenakshi Aggarwal MD PGY2 Family Medicine AAFP Journal Review March 20th, 2008

2. Discussion • Chronic Shoulder Pain Evaluation Diagnosis Treatment Testicular Cancer Diagnosis Treatment

3. Chronic Shoulder Pain • Pain present for > 6 months regardless of whether the patient has previously sought treatment

4. Categories • Rotator cuff disorders • Adhesive capsulitis • Glenohumeral OA • Glenohumeral instability • AC joint pathology • Other chronic pain

5. Rotator cuff disorders • Tendinosis • Full or partial thickness tears • Calcific tendinitis

7. Shoulder Muscles Movements Fwd Flex - Deltoid, Pec maj, Coracobrach, Biceps Extension -Deltoid, Teres maj, Teres min, Lat dorsi, Abduction - Deltoid, Supraspin, Infraspin, Subscap, Adduction - Pec maj, Lat dorsi, Teres maj, Subscap Int rotation - Pec maj, deltoid, Lat dorsi, Subscap Ext Rotation - Infraspin, Deltoid, Teres min

8. Clinical Diagnosis • Medical history Age Occupation Location of the pain Factors aggravating the pain Previous treatments

10. Physical Examination • Inspection • Palpation • Range Of Motion and strength tests • Provocative Tests

11. Inspection - Lt. sided atrophy

12. Palpation: Anterior Posterior

13. Range Of Motion: External Rotation Internal Rotation

14. Contd- Forward Extension Forward Flexion

15. Provocative Tests: Hawkin’s Impingement Test - Indicates rotator cuff tear or tendinopathy

16. Drop Arm Rotator Cuff Test:Indicates large rotator cuff tear Raise arm to 160 degrees. Patient is then asked to slowly lower the arm to the side. Positive test: Inability to control the lowering phase and dropping of the arm.

17. Empty Can Supraspinatus Test: Positive test is indicated by weakness compared with the other side. Indicates supraspinatus tear or tendinopathy Cross Body Adduction Test: Shoulder is passively adducted across the body. Pain may indicate AC joint pathology including chronic sprain or OA.

18. Apprehension Test: Arm is abducted to 90 degrees and shoulder flexed to 90 degrees. Pain and sense of instability with further ER may indicate shoulder instability. Ext Rotation/ Infraspinatus Strength Test: Arms are held to the side with elbows flexed to 90 deg, Positive test is inability to ext rotate against resistance. Indicates infraspinatus or TM tear or tendinopathy

20. Diagnostic Imaging • Plain X-rays: TOC* for OA of AC joint and glenohumeral joint, calcific tendinitis • MRI: TOC for rotator cuff disorders • Arthrography: TOC for labral pathology found in chronic shoulder instability • CT Scan: TOC for bony disorders (arthritis, tumors and occult fractures) • Ultrasonography * TOC: Test of choice

23. Q) Which one of the following statements about glenohumeral instability is correct? A. Onset typically occurs in patients older than 40 years. B. There is usually no history of subluxation or dislocation. C. There may be a history of a "dead arm" or numbness over the lateral deltoid on physical examination. D. There is usually no history of trauma or collision sports. Answer: C

26. Injections: Steroids + Anesthetic • Subacromial Injections: Rotator Cuff pathology • Intra-articular injections: Adhesive capsulitis • AC Joint Injections: Osteoarthritis • Glenohumeral Joint Injections: OA, rheumatoid arthritis, adhesive capsulitis

27. Injection Sites: Any Guesses?

28. Q) Which one of the following statements about adhesive capsulitis is correct? Patients not responding to treatment within one month should be referred for surgical intervention. B. Subacromial steroid injections have been shown to improve long-term outcomes. C. The natural history of the condition is to improve spontaneously after one to two years. D. Pain medication should be withheld to the greatest extent possible, given the chronic nature of the condition. Answer: C

30. Photo Quiz: • Churg-Strauss Syndrome • Eosinophilia-myalgia Syndrome • Strongyloidiasis • Wegener’s Granulomatosis • Well’s Syndrome Answer: A

31. Diagnosis And Treatment Of Testicular Cancer

32. Testicular Cancer • Most common cancer in the men 20-35 years of age • Annual incidence: 4 per 100,000 • Accounts for 1-2% of all neoplasms in men

33. Risk Factors • Cryptorchidism • Tobacco • Family History • Infertility • White race

35. Diagnosis • History • Physical Exam • Diagnostic Tests

37. Testicular Self Exam Patient places the index and middle fingers under the testicle with the thumbs placed on top. Patient should roll the testicle gently between the thumbs and fingers feeling for lumps. Patient shouldn't feel any pain when doing the exam.

38. Staging……. • Do we REALLY need to know?

39. Tumour Markers • Beta HCG • Alpha fetoprotein • Lactate Dehydrogenase

41. Role Of A Family Physician • Diagnose • Evaluate Recurrence • Future complications • Infertility issues: Encouraging the patient to bank sperms

43. Q) Which one of the following is the preferred initial diagnostic test for a patient with a scrotal mass?A. Magnetic resonance imaging.B. Computed tomography.C. Ultrasonography.D. Positron emission tomography. Answer: C

44. Q) Which one of the following statements about the clinical diagnosis of testicular cancer is correct? Intra testicular masses should be considered testicular cancer until proved otherwise. B. Pain on palpation rules out malignancy. C. Most patients present with symptoms of metastatic disease. D. Scrotal swelling is uncommon. Answer: A

45. Thank You!

46. Questions?