Drs P.M Bloemendaal, S. Eggermont, Drs E.M.
Schoonderwaldt
Mrs van Poppel, 26 years of age, is in the
waitingroom of the First aid where you are on call as a resident. She complains
about a painfull shoulder that she got while putting on her coat when she left
home.
10/07/2002 09:08 Location of your patient:
First aid What happened? I tried to put on my coat while I
was walking to the door to go out to get some groceries. Main
complaint "The pain in my shoulder is terrible." "Could you please
tell me what is the problem? Pain in the shoulder The patient is in
a lot of pain. Something has to be done right now. "Can't you fix my
shoulder, doc?" Joints in arms and legs No pain is reported in the
hips at the onset of movement. The patient reports having sprained her ankles
several time in the past, but not recently. The patient normally has no
problems moving the arms, no complaints of restriction in movements or pain in
the muscles. Momentarily the right arm can not be moved at all without terrible
pain. This is not the first time the patient experiences this particular pain
in the shoulder.
Inspection shoulders You compare the contour
of both shoulders. There is a slight, but unmistakable difference. The left
shoulder has a normal round shape, the right shoulder appears to be more
sharp-edged.
Inspection
shoulders
Keyboard phenomenon right Negative, no abnormal findings at the
clavicula.
Keyboard phenomenon
right
Inspection hands Normal color, good capillary refill. No
difference in left and right side.
Inspection hands
Active movement right elbow Full range flexion and
extension. Active abduction right arm Abduction is almost
completely impossible. The patient indicates pain in the right
shoulder. Passive adduction right arm You encounter a bouncing
resistance. The face of the patient turns pale from the pain.
X-ray shoulder in 2 directions is
requested.
Here are the results of you request
from:07/10/2002 09:10:
10/07/2002 10:01 X-ray shoulder in
2 directions X-ray not under- or overexposed. Structures clearly visible.
No deformation of the bones. The humerushead is dislocated
subcoracoidial.
For this case it is perfect to retrieve 50 points, while you may loose a
maximum of 50 points.
You scored 44 points and lost 0 points.
Your total score until now: 8.8
The costs of your actions are:
X-ray shoulder in 2 directions : 15
Diazepam injection 10 mg : 1.3
Repositioning right shoulder : 79
X-ray shoulder in 2 directions : 15
X-ray shoulder in 2 directions : 15
Sling : 10
Total costs: 135.3
You forgot something according to the author of this case:
Previous history points: 1 The result at this moment of Previous
history: Your patient was never admitted to hospital. No severe accidents, has
never bee seriously ill. Comments of the author: One should always inform
about the complaints and diagnosis in the past. Rachitic results in bone
deformations. There is however no connection with the current trauma.
Deterioration of pain points: 1 The result at this moment of
Deterioration of pain: Luckily the arm is in a sling right now, worn under the
clothing. Comments of the author: One of the dimensions of pain is
information about what makes the pain deteriorate or releases the
pain.
Radiation of pain points: 1 The result at this moment of
Radiation of pain: "The pain does not really radiate anymore, it is a lot
better then just before."
Shoulder trouble medical history points: 1 The result at this
moment of Shoulder trouble medical history: "During swimming my shoulder did
dislocate several times in the past." "Luckily it popped back almost
immediately back then."
Passive elevation right arm points: 1 The result at this moment
of Passive elevation right arm: This is not very careful. You just put the
shoulder back in place and right after this you try to dislocate it
again. Comments of the author: Every examination of an injury to an
extremity should include checking active an passive movement (in this
order).
Put hand on shoulder points: 1 The result at this moment of Put
hand on shoulder: You should take care that the shoulder is held as still as
possible after putting it back in place. An examination such as this one is
not sensible at this moment. Comments of the author: This examination is
especially significant if a dislocation of the humerus is
suspected.
Strength in arms and legs points: 1 The result at this moment of
Strength in arms and legs: No complaints of loss of strength or paralyzes. The
patient normally can move her arms and legs perfectly, but momentarily
not. Comments of the author: Loss of strength can be a sign of disorders of
the central or peripheral nerve system or muscle damage.
Inspection arms points: 1 The result at this moment of
Inspection arms: The right arm is in a sling. The sling is worn under the
clothing. Comments of the author: Deviation of the position of the arm
could indicate fracture or dislocation. Disorders of the joints can come to
light as swelling or redness.
Sensation in arms and legs points: 1 The result at this moment
of Sensation in arms and legs: The sensation in arms and legs in normal. The
patient does not complain of a numb feeling in fingers or toes. Comments of
the author: Benumbed or tinkling feeling in the limbs can point to disorders
of the central or peripheral nervous system.
Tumbling points: 1 The result at this moment of Tumbling: "Yes,
I did fall down. When I opened the door and put my arm in my sleeve, I
suddenly felt a severe pain in my shoulder and fell sideways." Comments of
the author: One should find out what happened as precisely as
possible.
Capillary refill points: 1 The result at this moment of
Capillary refill: Normal capillary refill. Comments of the author:
Capillary refill is intact in normal blood circulation of the skin. If
circulation is inadequate, capillary refill is disturbed.
Loss of consciousness points: 1 The result at this moment of
Loss of consciousness: "No I have not lost consciousness the whole time."
Comments of the author: A trauma to the head and loss of consciousness
could occur as a complication of a tumble.
Active elevation right arm points: 1 The result at this moment
of Active elevation right arm: After repositioning the arm, you should fixate
the arm to prevent the shoulder from dislocating again. You should instruct
the patient not to lift the arms. Comments of the author: Every examination
of an injury to an extremity should include checking active an passive
movement (in this order).
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