Case Study Analysis – 65-Year-Old White Female

Case Study Analysis – 65-Year-Old White Female

Diagnosis and Treatment

The case study is about a 65-year-old white female who fell forward with her left arm

extended and landed on her left shoulder. Rotator cuff tendinopathy is the diagnosis. Rotator cuff tendinopathy is a shoulder ailment caused by repeated lifting and reaching. It may cause shoulder stiffness, discomfort, and a restricted range of motion. It is crucial to identify and treat this illness before it becomes chronic and causes long-term impairment (Varacallo & Mair, 2019). The treatment regimen includes NSAIDs like ibuprofen (600-800mg three times a day) to decrease inflammation and discomfort, corticosteroid injections to minimize inflammation and discomfort, and physical therapy to strengthen shoulder muscles.

Differential Diagnoses

Shoulder impingement syndrome is the first potential differential. Athletes and others who use their shoulders may suffer from shoulder impingement syndrome (Creech & Silver, 2020). Shoulder tendonitis is caused by overuse or repeated action, causing inflammation of the tendons and muscles of the shoulder. Pain while elevating the afflicted arm, shoulder weakness, and discomfort when sleeping on the painful side are all symptoms. Shoulder impingement syndrome is a potential differential diagnosis because the patient has a history of shoulder immobilization and the use of anti-inflammatory drugs.

Rotator cuff tear is the second possible cause. Older persons, particularly those with a history of shoulder injury or repeated activities, may suffer from rotator cuff tears. Pain, stiffness, and weakness in the shoulder and arm are all symptoms. This happens when one or more rotator cuff tendons are torn (May & Garmel, 2020). The patient’s fall history and subsequent restricted shoulder mobility may indicate a rotator cuff injury.

Frozen shoulder or adhesive capsulitis, is the third possible cause. Adults over 40 have an increased risk of developing adhesive capsulitis. It causes shoulder discomfort, stiffness, and restricted movement. This is because inflammation and stiffness in the joint are brought on by the joint capsule thickening (Mezian & Chang, 2020). An adhesive capsulitis diagnosis may be considered given the patient’s advanced age, restricted range of motion, and lack of response to the shoulder immobilizer and anti-inflammatory medicine.

Rule Out/Rule In Differentials

The potential of the differentials cannot be ruled out until more testing and research are conducted. An MRI or ultrasound examination is required to diagnose shoulder impingement syndrome with certainty. Medical professionals must do an MRI and electromyography (EMG) to detect a rotator cuff tear. Adhesive capsulitis can only be diagnosed with imaging tests like an X-ray or MRI (Mezian & Chang, 2020). The patient’s medical history and the physical examination findings will be used in conjunction with the results of the physical tests to rule out or confirm the possible differential diagnoses.

Rotator cuff tendinopathy is the diagnosis. Rotator cuff tendinopathy is a shoulder ailment caused by repeated lifting and reaching. It may cause shoulder stiffness, discomfort, and a restricted range of motion. It is crucial to identify and treat this illness before it becomes chronic and causes long-term impairment (Varacallo & Mair, 2019). The treatment regimen includes NSAIDs like ibuprofen (600-800mg three times a day) to decrease inflammation and discomfort, corticosteroid injections to minimize inflammation and discomfort, and physical therapy to strengthen shoulder muscles.

Treatment Plan and Medication Doses

The treatment plan and medication doses will depend on the diagnosis. For shoulder impingement syndrome, treatment may include rest, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-600 mg three times a day) or naproxen (500-1000 mg twice a day), and corticosteroid injections (methylprednisolone 30-40 mg) (Pledger, 2018). For rotator cuff tear, treatment may include rest, physical therapy, NSAIDs such as ibuprofen or naproxen, and surgery (“Adhesive Capsulitis (Frozen Shoulder) Treatment & Management: Approach Considerations, Medical Therapy, Extracorporeal Shockwave Therapy,” 2019). For adhesive capsulitis, treatment may include physical therapy, NSAIDs such as ibuprofen or naproxen, and corticosteroid injections (methylprednisolone 30-40 mg).

Conclusion

In conclusion, the case study presented is of a 65-year-old white female who has sustained a fall forward with an outstretched left arm, bracing her fall and subsequently landing on her left shoulder. Subsequently, she has a limited range of motion in abduction, adduction, and internal and external rotation. Three possible differential diagnoses have been discussed: shoulder impingement syndrome, rotator cuff tear, and adhesive capsulitis. Further tests and evaluations have been recommended to rule out or rule in the differentials. Finally, a treatment plan has been suggested, which includes physical therapy, medications, and lifestyle modifications.

 References

Adhesive Capsulitis (Frozen Shoulder) Treatment & Management: Approach Considerations, Medical Therapy, Extracorporeal Shockwave Therapy. (2019). EMedicine. https://emedicine.medscape.com/article/1261598-treatment

Creech, J. A., & Silver, S. (2020). Shoulder Impingement Syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554518/

May, T., & Garmel, G. M. (2020). Rotator Cuff Injury. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547664/

Mezian, K., & Chang, K.-V. (2020). Frozen Shoulder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482162/

Pledger, D. (2018). UND Scholarly Commons The Effectiveness of Oral Nonsteroidal Anti-Inflammatories versus Steroid Injections in Patients with Shoulder Pain. https://commons.und.edu/cgi/viewcontent.cgi?article=1019&context=pas-grad-papers

Varacallo, M., & Mair, S. D. (2019, June 4). Rotator Cuff Tendonitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532270/

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Case Study

A 65-year-old white female sustains a fall forward, with her outstretched left arm bracing her fall, and lands on her left shoulder. She is out of the country when the injury occurs. She uses a scarf as a sling for support. On return home, she sees her PCP. She has limited ROM to abduction, adduction, internal, and external rotation. An x-ray was ordered, and no fractures were observed. She is placed in a shoulder mobilizer and given an anti-inflammatory. She regains her mobility with some continued soreness.

Case Study Analysis – 65-Year-Old White Female

Three months later, the patient developed severe pain in her left shoulder. She cannot turn over in the bed due to pain. She cannot raise her arm over her head, and the limited ROM has returned.
Provide specific treatment plan including medication dose

What would be your diagnosis and treatment plan?
Please list three differential diagnoses.
Make sure you rule in or rule out the differentials.