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    Week 8 Portfolio Questions

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    Allan is a 30-year-old man who presented with left shoulder pain after a basketball injury. Over the next month, the pain worsened and spread to his entire left arm. He had difficulty holding objects and pain with typing. On examination, his left arm skin was shiny with swelling and tenderness. The likely diagnosis is complex regional pain syndrome affecting the upper limb. Further investigation and a referral may be needed for pain management.

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    Week 8 Portfolio Questions

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    api-479716004
    24 views2 pages
    Allan is a 30-year-old man who presented with left shoulder pain after a basketball injury. Over the next month, the pain worsened and spread to his entire left arm. He had difficulty holding objects and pain with typing. On examination, his left arm skin was shiny with swelling and tenderness. The likely diagnosis is complex regional pain syndrome affecting the upper limb. Further investigation and a referral may be needed for pain management.

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    Allan is a 30-year-old man who presented with left shoulder pain after a basketball injury. Over the next month, the pain worsened and spread to his entire left arm. He had difficulty holding objects and pain with typing. On examination, his left arm skin was shiny with swelling and tenderness. The likely diagnosis is complex regional pain syndrome affecting the upper limb. Further investigation and a referral may be needed for pain management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    24 views2 pages

    Week 8 Portfolio Questions

    Uploaded by

    api-479716004
    Allan is a 30-year-old man who presented with left shoulder pain after a basketball injury. Over the next month, the pain worsened and spread to his entire left arm. He had difficulty holding objects and pain with typing. On examination, his left arm skin was shiny with swelling and tenderness. The likely diagnosis is complex regional pain syndrome affecting the upper limb. Further investigation and a referral may be needed for pain management.

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    of 2

    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.

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