Glenohumeral Arthritis (Shoulder Arthritis) Pathway Posted: 6/5/2022 ID: (C102059) Middle Atlantic Shoulder & Elbow Society Annual Meeting

Shoulder Pain in 62M

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CASE DESCRIPTION

AGE	62 / Male
CC	Right shoulder pain
HPI	A 62-year-old male, right-hand dominant, presents with chronic right shoulder pain for many years. He has noted progressively decreased function and has failed a course of physical therapy, NSAIDs and corticosteroid injections. He is a laborer and wishes for pain relief and increased function.
PMH	PMH/PSH: non-contributory
PE	Focused physical examination of the right shoulder reveals no prior incisions. He has active forward flexion to 80, ER to 5, and IR to his sacrum. He has 5/5 deltoid and rotator cuff strength. He is neurovascularly intact.

AGE/GENDER:

62 / Male

CHIEF COMPLAINT:

Right shoulder pain

HISTORY OF PRESENT ILLNESS:

A 62-year-old male, right-hand dominant, presents with chronic right shoulder pain for many years. He has noted progressively decreased function and has failed a course of physical therapy, NSAIDs and corticosteroid injections. He is a laborer and wishes for pain relief and increased function.

PAST MEDICAL HISTORY:	PMH/PSH: non-contributory
PHYSICAL EXAM:	Focused physical examination of the right shoulder reveals no prior incisions. He has active forward flexion to 80, ER to 5, and IR to his sacrum. He has 5/5 deltoid and rotator cuff strength. He is neurovascularly intact.
DIAGNOSIS:	Shoulder Pain in 62M