Painful Shoulder Medical Treatment - Case Study Example

Patient. C.Age: 38 years. FemaleThe patient was brought to the unit on a stretcher after being involved in a motorcycle accident. The patient was in pain but alert and fully oriented. Bleeding had been arrested and the affected area bound with a white clean cloth by the well-wishers. The patient signed the consent for examination and care and gave her own history (Greaves and Johnson 2002, p.74).PC: Painful shoulder joint.HPC: the patient was well until an hour ago when she was riding her motorcycle home from work.

She was involved in an accident and landed on the lateral side of the right shoulder. She did not lose consciousness felt intense pain after the collision with the ground. PMH: Normal childhood and youth. No major illness.Weight: 71kg.Medication: Reportedly given anti-inflammatory analgesics (Diclofenac 50mg tab) by a friend on the way here. Has not been on any other medication recently.Allergies: The patient is reactive to sulphur and sulphur-containing compounds. There is no known food allergy.

Immunisation: Up to date for her ageSH: The patient is a mother of two boys, the youngest being 7 years old. She is single and lives with the two boys and a younger sister. She is a business woman and travels to and from work daily on her motorcycle. She does not smoke or take alcohol.O/E: Looks stable and well oriented. She is however in pain but can walk in her own without support (Davies et al. 2011, p.6). She gives her own history,Head and Neck: NADTrunk: NADHands: slight bruising on the right palm.

Patient was wearing riding gloves during the accident. Right shoulder:Anterior Aspect: Minimal swelling over the SC Joint, Clavicle, AC Joint and Trapezius muscle, slight bruising with no obvious deformity, no visible wound.Bony tenderness noted over the SC Joint, Clavicle, AC Joint. No bony tenderness over the Acromion Process, coracoid process, non - tender on deltoid muscle, pectoralis major and biceps muscleNerves: Regimental Badge Sign Tested-full sensation noted on deltoid muscle- Axillary, Brachial Plexus, Median, Ulnar and Radial nerve-sensation intact and compare to the left arm.

Posterior Aspect: No bruising or obvious deformity, no erythema or wound, skin intact compare to left shoulder.Slight Tenderness over the trapezius muscle, non-tender over the scapula, acromion process, Supraspinatus muscle, Infraspinatus muscle and Latissimus Muscle.Active Movement: Retraction-reduced and painful over the shoulderProtraction-reduced and painful over the shoulderElevation-reduced and painful over the shoulderDepression- Full range; pain free movement Abduction-reduced and painful on shoulderAdduction-reduced and painful on shoulderInternal Rotation-reduced and painful on shoulderExternal Rotation-reduced and painful on shoulderRight Elbow:NAD-Brachial and Radial pulse –present and strong compared to left arm-no altered sensation/well perfused-capillary refill