Differential Diagnoses Assignment Answer Sheet
NURS 5305 Adult Management
68 year old man presents with pain in the right shoulder. He states that it came on while lifting a box down from a shelf. He thinks that the symptoms started about 3 weeks ago, now he finds it difficult to lift his arm above his head. The pain itself has gotten worse, and “interesting, that the pain is worse when he tries to go to sleep at night”. He has never had anything like this scenario before; he has used heat, ice and rub-on liniments without relief. He has taken a few OTC Aleve with some relief, but they caused a little bit of heartburn [and when the effect wore off in 8 hours or so, the symptoms seemed to return, unchanged in nature]. No pain per se, as long as he is seated/resting and his arm is flush with his lateral thorax. The patient is right handed.
PMH—Asthma; Allergic Rhinitis; no previous surgeries; NKDA
Meds—Flovent Diskus 100 mcg  inhalation BID; Flonase nasal spray 1-2 sprays each nostril once or twice per day; Singular 10 mg qd
SH—retired accountant; prior to the symptoms, enjoyed playing 18 holes of golf twice per week; nonsmoker [never has smoked]; 2 glasses of red wine every night [for last 25 years]
ROS is unremarkable except for shoulder pain; patient says allergies and asthma are well controlled
On exam, you see a young appearing Caucasian male; he is well groomed. VS: 98-80-130/80 6’2” 220 pounds
CV/Resp: lungs are CTA a/p; no barrel chest or clubbing; heart is RRR, no murmur/gallop/rub; no edema
Upon inspection, you see no deformity of either shoulder; you can appreciate some tenderness along the top of the right humeral head. The patient winces with pain upon abduction of the arm beginning at 45 ⁰; normal strength in shoulders bilaterally. With active ROM, RUE can be abducted to ̴ 60 degrees; with passive ROM, patient can abduct RUE no more than 40-45 degrees. Flexion/extension at level of the elbow is normal bilaterally; patient does c/o some pain with internal rotation of the humerus; you cannot appreciate any crepitus of either shoulder upon exam; Hawkin’s test is + on the right.
_______40% Medical Diagnosis and ICD-9 Code(s):
Supraspinal tendon injury : ICD – 9, code 726.10
Asthma: ICD 10 –J45
Allergic rhinitis: ICD 477.9
Differential Dx #1: brachial plexus injury
Differential Dx #2: long head of biceps tendon injury
Differential Dx #3: acramioclavicular joint injury
Differential Dx #4: osteoarthritis
Pertinent Nursing Dx or Health Maintenance/Social Issue:
Knowledge deficit related to the disease process
Selfcare deficit related to shoulder injury
Pain related to the disease process
Initial Treatment Plan
X-ray of the shoulder to identify if there is bone pathology.
Lab investigations for blood works including full blood count.
Panadol 1g x 3/7
Range of motion exercises
Amoxyl 500mg tds x 5/7
Flovent Diskus 100 mcg  inhalation BID;
Flonase nasal spray 1-2 sprays each nostril once or twice per day;
Singular 10 mg qd
________20% Nursing Interventions / Education
Nursing interventions will include goals of restoring function, relieving pain, and self care. For the management of pain, the patient can be taught to adapt to lifestyle and avoid movements that can potentially trigger the pain. That will mean he avoids certain activities in his day to day life. The spouse will also be taught alongside so that she can help him with it, and also avoid injury by mistake.
Patient will be taught how to maximize self care without moving the shoulder in a manner that will trigger the pain. This is important because the patient should remain as independent as is safe for him.
______ TOTAL (100%)