Week 8 CASE STUDY 8 CHIR13009

CASE STUDY AND QUESTIONS: To be completed by the 13 th September

Week 8 Case Study 8 Allan

Allan is a 30-year-old financial planner.

Presenting Complaint

Allan fell on his left shoulder during a game of basketball. The pain in his left
shoulder occurred immediately after the incident.

History of Presenting Complaint

An x-ray taken at the time showed no evidence of fracture. Over the next one
month, the pain worsened: the pain was now in his entire left arm as well as his
shoulder. He described the pain as a burning and throbbing quality with tenderness
and coolness of the left hand and wrist. He also noted that his skin had become
shiny and he had difficulty holding objects such as a pen or kitchen utensils. Typing
also caused pain in the left arm and shoulder. There is no history of past illness or
familial arthritis and he had been on no medications.

Physical Examination

Allan appears tired and a little pale.

Vitals:
Pulse rate was 90/min, regular, and strong. Respiratory rate 16/min; BP 120/75
There was pallor of the conjunctiva, but not the palmar creases.
On examination, the skin of the left arm was slightly shiny compared with the right
arm. Swelling and oedema were also present. The left arm was hypersensitive to
touch. His radial pulses and capillary filling were symmetrical and normal.

Questions

1. What other further pertinent questions should you ask this patient?

Continue through LODCTRAPPA questioning

2. For the above case history alone, what are your differential diagnoses?

Complex regional pain syndrome, Cervical disc (C5,6), Thrombosis, lymphoedema

Week 8 CASE STUDY 8 CHIR13009

3. Outline an examination routine that would eliminate or confirm your differential

diagnosis mentioned in question 2.

The diagnosis would have most likely been reached just through the GORP
component of the assessment due to the presenting symptoms

4. Using only the information from the above case history and physical examination,
what is the likely diagnosis:

a. For his upper limb problem

CPRS – shinny complexion of skin is a give away

b. For his other physical signs

IBS – Stress levels and bowl movements are a good indication

5.Do you need to refer this patient? Are there any investigations which should be
done?

The patient will need to be referred perhaps for strong pain relief.