THIS PATIENT DATA WAS GATHERED BY ROLL NO 12 A BATCH 2024 AS PART OF HIS COMPETENCE BASED LEARNING EVALUATION PORTFOLIO PREPARATION
THIS IS THE CASE OF 51M WITH LEFT SHOULDER PAIN AT THE SUPRACLAVICULAR REGION SINCE 3 MONTHS. PAIN IN THE LEFT LOWER BACK, SOB
*General Medicine - Case Taking*
- *Age / Sex:* 51 years / Male
- *Occupation:* Worker in a textile shop
- *Marital Status:* Married
- *Education:* 7th standard
*Chief Complaints (C/C)*
- Pain in the left shoulder at the supraclavicular region since 3 months
- Pain in the left lower back, lower thoracic region on the midaxillary line
- SOB when climbing the stairs
*History of Present Illness (HOPI)*
- Onset since 3 months
- Pain when getting an overload on the site or lifting heavy loads
- Pain radiating to shoulder to the neck, left side
*History of Present Illness - Continued*
- 3 months ago patient was drunk & slept without a proper posture & consciousness (Saturday night palsy).
*History of Past Illness*
- The patient is known to have HPT at the time of pain consulting from the primary consultation.
- Metabolic syndrome is seen.
- Mild D.M.
- Swelling in the legs 3 months ago.
- N/H/o TB, Bronchial Asthma, Epilepsy.
- H/o minor surgery in the ear due to infection.
*Personal History*
- Diet: Mixed
- Appetite: Normal
- Sleep: Disturbed when done heavy work
- Bowel & Bladder: Normal
- Body appearance: Central abdominal fat deposit
- Muscle tone is normal
- A little wasting noticed in the left arm
- Alcohol: Yes (2-3 times a week)
- Physical Activity: Active
*Family History*
- Not significant
*General Examination*
- Patient is conscious, coherent, oriented to Time, Place, Person
- P - Pallor: Absent
- I - Icterus: Absent
- C - Cyanosis: Absent
- C - Clubbing: Absent
- L - Lymphadenopathy: Absent
- E - Edema: Absent
- D - Dehydration: Absent
*Vital Signs*
- Temperature: Afebrile
- Pulse: 58 / min
- R.R.: 19 / min
- BP: 139/91 mmHg
- SpO2: 96% on Room Air
*Systemic Examination*
- R.S.: Normal vesicular breathing sounds
- C.V.: S1, S2 (+)
- C.N.S.:
- Higher functions: Normal
- Sensory: Normal
- Cerebellar: Normal
- Cranial nerves: Normal
- Motor System: Normal
- Reflex: Normal
*Examination Finding*
- Restricted movement of the left arm above 90° upwards.
*Diagnosis*
- The diagnosis for the above case is Frozen Shoulder / Adhesive Capsulitis.
- Due to strain to the ligaments of the shoulder joint & strain to the thoracic nerve.
Here is a structured set of Socratic questions based on the clinical case from the report, designed to guide medical students through clinical reasoning, pathophysiology, and management.
1. Patient Profile & Pathophysiological Links
* Question: The patient presents with left shoulder pain, but his history notes a prior episode of "Saturday night palsy" and metabolic syndrome with mild diabetes. How do conditions like diabetes mellitus and metabolic syndrome pathologically predispose a patient to adhesive capsulitis (frozen shoulder)?
* Question: He also reports central abdominal fat deposition and shortness of breath (SOB) on climbing stairs. Could his dyspnea and metabolic profile alter your approach to physical rehabilitation or physical therapy? Why?
2. History Taking & Etiology
* Question: The history reveals that 3 months ago, the patient was intoxicated and slept in an improper posture ("Saturday night palsy"). What is the distinct difference between nerve compression injuries (like Saturday night palsy) and structural joint pathology (like adhesive capsulitis)? How would you clinically differentiate between them during an examination?
* Question: The patient notes that his pain radiates from the shoulder to the left side of the neck, along with left lower back pain. How can you determine whether the neck and shoulder pain are part of a single radicular source versus two distinct musculoskeletal issues?
3. Physical Examination & Clinical Findings
* Question: The examination notes restricted movement of the left arm above 90^\circ upwards. When evaluating range of motion (ROM), why is it clinically vital to test and compare both active and passive range of motion? What does a restriction in both active and passive ROM typically point toward?
* Question: The physical exam describes "a little wasting noticed in the left arm". If muscle wasting is present alongside chronic shoulder pain, what structures should you carefully re-evaluate to rule out a compounding rotator cuff tear or chronic disuse atrophy?
4. Diagnosis & Differential Thinking
* Question: The final diagnosis is given as Frozen Shoulder / Adhesive Capsulitis, attributed to strain on the ligaments of the shoulder joint and the thoracic nerve. What are the classic stages of adhesive capsulitis (freezing, frozen, thawing), and which stage does a 3-month duration of progressive restriction typically represent?
* Question: What other differential diagnoses must you rule out in a 51-year-old worker presenting with acute-on-chronic shoulder pain and restricted elevation (e.g., subacromial bursitis, calcific tendinitis, glenohumeral osteoarthritis)?
5. Management & Comprehensive Care
* Question: Given that the patient is a textile shop worker requiring physical activity, how would you design a conservative management plan that balances necessary joint mobilization with his occupational demands?
* Question: Considering his history of hypertension, mild diabetes, and alcohol use (2–3 times a week), what precautions or side effects must you keep in mind if you choose to prescribe NSAIDs or administer intra-articular corticosteroid injections for pain management?
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