Musculoskeletal System

Mrs. Johnson is a 73 y.o. female who presents to your office with right shoulder pain. Her and her husband just moved to the area a few months ago, and you have only seen her once for a sinus infection. Today she states that she is having increasing right shoulder pain over the past couple of weeks. She explains that her shoulders have “always bothered” her because she worked in a factory moving boxes for years. She states that she uses naproxen, “prescription strength” and that usually does the trick when her arthritis flares up, but she is out and would like a refill.

On exam, you note that her right shoulder is tender to palpate, and she has limited motion. She smells of BenGay but otherwise, she seems healthy. The area is edematous and when asked she does agree that her arm seems swollen. She denies any falls but remembers that she lost her balance and fell backward into her recliner a few days ago “kind of hard” but she caught herself when she grabbed for the coffee table. Otherwise, she does not recall any injuries. You decide to send Mrs. Johnson for an x-ray and she is in the waiting room until you get the results back.

Questions

1.        What is in your differential diagnosis (top 3 minimum) as you think through this case?

2.        What would you order, if anything?

3.        What else would you like to ask Mrs. Johnson relating to how she may have been injured?

4.        There are at least two areas of concern on this x-ray—one is a pathological fx of her humerus. Research pathological fractures; review the physiology of the musculoskeletal system and compare and contrast this knowledge with this pathophysiological condition.

5.        After focusing on the pathophysiology of the fractured bone, discuss what other disorder you suspect from a review of the x-ray.

6.        What would be your primary choice for an underlying diagnosis for Mrs. Johnson, and why?

7.        What past pertinent information related to a pathological fracture and your second suspected diagnosis would you like to ask Mrs. Johnson?

8.        Are there any additional tests, radiological studies, etc. that you would order for Mrs. Johnson?

9.        Will you refer this patient, and if so, to whom?

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