|
|
Re: case right shoulder pain
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: case right shoulder pain - March 5, 2006 10:34:00 AM
|
|
|
FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
|
you palpate right lower abd quadrant and it reproduces her right shoulder pain. A mass that protrudes up to the right hemisphere of the diaphragm can put pressure on the phrenic nerve which can refer pain to the right shoulder. Right shoulder pain usually indicates irritation of the undersurface of the right hemi-diaphragm and consequent stimulation of the phrenic nerve with referred pain to the right shoulder.
This can be seen with significant hemoperitoneum (ruptured tubal ectopic pregnancy, sometimes ruptured ovarian cysts), free air (ruptured diverticulum or appendix), or pus (moderate-severe PID).
These findings are significant, and may mean she had a miscarriage of an ectopic pregnancy when she was hospitalized and infection, bleeding, irritation, etc could have set in or still been present causing her symptoms. This is clearly a GI or OB GYN issue, most likely OB/GYN and should be referred rather immediately.
This is just an example of vague musculoskeletal pain that a lot of us can have, vague shoulder pain, that can be often misdiagnosed, as we all know, but especially when an ortho is doing the screen. It is not uncommon to see an ortho omit a systemic review, so as possible point of entry providers, we need to be on the lookout for pain that does not quite match the eitiology of the symptoms. As we can see here, she most likely has some sord of cysts, or ectopic pregnancy, or something similar causing her shoulder pain, and we should refer on.
The rest is FYI from a military OB GYN webiste:
http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbdominalPain/AbdominalPain.htm
Temperature greater than 100.4 favors appendicitis, pyelonephritis, septic abortion, and moderate-severe PID. Temperature less than 99 is not often seen in these conditions.
Elevated pulse >100 is seen in hypovolemia (ruptured ectopic pregnancy), fever, and increased metabolic states (pyelonephritis, PID)
Diffuse tenderness is associated with ruptured ectopic pregnancy, gastroenteritis, functional bowel syndrome and bowel obstruction.
Upper abdominal tenderness is rarely associated with gynecologic illness.
Right lower quadrant tenderness increases the likelihood of appendicitis, ectopic pregnancy, ovarian cystovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.
Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, mittelschmerz, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.
Suprapubic pain favors cystitis, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.
The presence of voluntary guarding implies the patient is consciously protecting a sore area within the abomen, such as appendicitis, ovarian cyst, ectopic pregnancy, PID.
Involuntary guarding and moderate/marked rebound tenderness are characteristic of peritonitis, such as might be seen in appendicitis, moderate-severe PID, ruptured ectopic pregnancy, torsioned ovarian cyst, diverticulitis, or bowel obstruction.
|
|
|
|
|
Re: case right shoulder pain - March 6, 2006 3:03:00 PM
|
|
|
jma
Posts: 2310
Joined: August 24, 2000
From: NY
Status: offline
|
Nice case study FLAOrthoPT!!
|
|
|
|
|
Re: case right shoulder pain - March 6, 2006 4:24:00 PM
|
|
|
FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
|
thanks, i think this is what this forum is for right! rather than arguing chiro vs pt, I'd rather learn some things while I'm here! your turn now
|
|
|
|
|
Re: case right shoulder pain - March 9, 2006 7:05:00 AM
|
|
|
Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
Status: offline
|
To be honest - i was not trying to do the case - was just asking to see what people mean when they say "Cardiopulmonary systems are clear" - does that mean they say they are clear? that they are not diagnosed? etc etc etc -
Great case!
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
|
|
|
|
|
Re: case right shoulder pain - March 11, 2006 5:29:00 AM
|
|
|
Dr.Wagner
Posts: 1237
Joined: January 24, 2003
From: Indianapolis
Status: offline
|
I am trying to stay out of this...
But. Ruptured ectopic is an immediate emergency and immediate surgical consultation. So it is not ruptured...I really want to help you guys FOCUS. RARELY does ruptured ANYTHING not cause an emergent issue.
Fever needs to be focused with infection...period.
Abdominal pain needs to be considered BAD BAD BAD.
Referred pain needs to be considered.
Fever and abdominal pain is NEVER NEVER to be taken lightly. In a female you need to consider PID, Pyelonephritis, stone with pyelonephritis, toxemia of pregnancy, ovarian abcess, CHOLECYSTITIS, diverticulitis etc
To help with the consultation...IF AT ANY POINT you suspect a diagnosis out of the realm of PT treatment, REFER IMMEDIATELY.
Medico-legally speaking, you would be sighted for the DELAY of TREATMENT and MEDICAL DIAGNOSIS. Then PAIN and SUFFERING. Then LOST WAGES. It goes on and on. Looking at $100k to $1mil. NEVER NEVER NEVER delay suspected abdominal pathology to the appropriate medical referral.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.063
|
Printable Version
