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Shoulder Case 1: Notes

Rachel is a 43 year old woman who presents to your clinic with shoulder pain following a fall 3 weeks ago. Rachel was tidying her wardrobe when she fell off a small step ladder and landed on her right shoulder. She has not yet seen a health professional about her shoulder. During your subjective examination you find the following:

  • P & N / N = nil
  • Right hand dominant
  • Aggs = reaching over head, driving car, getting dressed
  • Eases = codiene forte, Ibuprofen gel, not using right arm
  • 24hr = wakes at night whenever she rolls onto it, pain worst in the morning, pain during the day depends on amount of movement
  • Social Hx = runs 3x per week, works as a fashion stylist, lives at home with husband
  • Current Hx = able to perform most ADLs however still painful, can’t hang up washing, pain has decreased since MOI but still rates it as constant throb 3/10 and sharp catching on movement at 7/10
  • Health Hx = no prior shoulder injuries, generally healthy, taking codeine forte and topical NSAID gel daily for pain, stable weight, nil cardiac conditions or diabetes

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