Case Summary

Patient Name: Case 1 shoulder Intern Name: Chelsea Graving Date: 23/07/2021

New Patient Case Write Up Supervisor Comments

This section must be completed and presented to the clinical supervisor within
seven days of the completion of the examination
1. Pertinent History (chief complaint, history, past medical history, psychosocial, and family history)
50 yr old woman presents with Left shoulder pain . The patient reported The pain is sharp at 7/10. It Began
intermittently and gradually worseing approx 10 months ago. Aggravated by moving her L shoulder in most
directions and reaching overhead.
medical history is remarkable for hypertension and OA. She is medicated with Altace and nurofen. Father passed
of Myocardial infarct and mother has diabetes mellitus.
The patient reports smoking 10 cigarettes a day, drinks socially. On extended sick leave from administrative job
as of 6 mnths ago.

2. Differential Diagnosis
DX 1 Chronic - intermittent/progressing- severe- Left sided Supraspinatus impingement
DX 2 Chronic - intermittent/progressing- severe- Left sided adhesive capsulitis
DX 3 Chronic - intermittent/progressing- severe- congestive heart failure
DX 4 Chronic - intermittent/progressing- severe- Left sided tumour in shoulder region

3. Pertinent Physical Examination

(Working off CAT 3) PR 86/RR18/BP130/90, T36.6, BMI 29
slightly reduced peripheral pulses 2+ apex beat displaced as palpated between mid clavicular line and axillary
line. Pallor of conjunctiva. Low haemoglobin count. appears pale, 50% reduced AROM Cervical spine in L rot and
L Lat Flexion, L shoulder decreased ROM painful in all ranges . Cervical spine tension, tight paravertebral m's
joint restrictions C4-C7. +ve cervical kemps, -ve obriens, Hawkins and neers. Xray - chondrosarcoma present.
4. Diagnosis
Chronic - intermittent/progressing- severe- Left sided chondrosarcoma (osteolytic lesion involving humeral head
and neck with associated pathological fracture)

5. Treatment plan including interventions

Refer directly on to GP for further investigation and immediate treatment.
6. Prognosis including barriers to recovery
Poor prognosis with the 50 yr old patient as the condition has been ongoing for almost a year and the tumour
from the imaging looks very progressed. Barriers to treatment would be patient not taking on referral.

7. Outcome Measures
Would not be completed as would be direct on referral.

8. Further investigations (if relevant)

Would be direct on referral where doctor (oncologist) can take over further investigations.

9. Suggested References and further reading

NA

Supervisor Conditional Approval: Date:

Supervisor Approval: Date: