Impingement Flashcards
Introduction
- *W**ash hands
- *I**ntroduce yourself
- *P**atient’s consent
- *E**xplain procedure/purpose for Hx
PC
“What brought you in today?”
HPC
Takes a focussed history including features of the pain:
Onset - “when did it start?”, “did it start suddenly or gradually?”
Duration - “how long have you had it for?”, “is it constant throughout the day or is it worse at particuar times of the day?”, “is it worse in the morning or evening?”
Aggravating & relieving factors (G if asks dominant hand) - “which is your dominant hand?”, “does anything make it better?”, “have you tried anything for this pain?”, “did it help?”, “does anything make it worse?”
Radiation, stiffness and night pain (G if 2 or more) - “does the pain move anywhere else?”, “do you get any stiffness? Is this worse in the morning or evening?”, “do you get any pain in the night? Does the pain wake you up?”
Other joint aches/pains e.g. neck - “have you got pain in any other joints like your neck, hip or back?”
Pins/needles and weakness (G if both) - “do you get any pins or needles, or any weakness in your affected arm?”
Cough/ SOB/ chest pain (1= A, 2+=G) - “have you had any recent cough?”, “have you recently felt short of breath?”, “do you have any recent chest pain?”
History of trauma - “have you been involved in an accident or had trauma to the affect arm?”
Fever/weight loss - “have you had any recent fevers?”, “any recent unintented weight loss?”
ICE
Ideas - “what do you think could have caused your shoulder pain?”
Concerns - “is there anything that your worried about regarding your shoulder pain?”
Expectations - “what were you hoping we would do for you today?”
Ask why the patient decides to present now and not earlier - “did anything influence your decision to come now and not earlier?”
PMH
- “Do you have any medical conditions like rheumatoid or osteoarthritis? Any previous cancers?”*
- “Have you ever had anything like what you’re experiencing in the past?”*
DH
- “Are you on any medications that have been prescribed by your doctor?”, “do you take any over the counter medications?”*
- “Do you have any allergies to any medications? What happens when you take the medication?”*
FH
“Do you have any FHx of rheumatoid/osteoarthritis, polymyalgia or frozen shoulder?”
SH
Alcohol, smoking, recreational drugs (including IVDU) - “do you smoke?”, “how much do you smoke each day?”, “how long have you smoked for?”, “have you ever smoked? How much did you smoke and for how long?”(if the patient said they don’t smoke),”do you drink?”, “how much/what do you drink each day?”, “do you use recreational drugs?”, “have you ever injected drugs or shared needles with other people?”
Occupation - “do you work?”, “what do you do for work?”
Home situation - “what’s your home situation like?”, “do you need help with things like cooking, washing/cleaning yourself?”
Examination
Asks to examine patient with examples (e.g. shoulder examination) + shows awareness that movements are painful
“I’d like to examine you now by having a look at your shoulders and arms and getting you to do some movements. Please let me know if you experience pain at any point, and we can stop the examination if you’d like us to. Is this ok with you?”
Inspection of muscle bulk (G for contrasting both sides)
Elicits pain on abduction at 60- 90 degrees in affected arm
Elicits pain on internal/external rotation
Shows awareness that movements may be painful
DDx
Makes diagnosis of impingement (G if explanation)
“From our discussion and examination, it is likely that you have shoulder impingement. This is when tendons of muscles (rotator cuff) in your shoulders rubs or catches on nearby tissue/bone as you lift your arm.”
Counselling
Offers referral to physiotherapy/exercise sheet - “I can refer you to the physiotherapist and they can discuss with you exercises that may help with your symptoms. In the meantime, I’ll give you an exercise sheet of exercises you can try whilst you wait for an appointment”
Offers sick note for modification of activity - “I could also give you a sick note, to give you some time to avoid doing any heavy activities that may make your symptoms worse”
Presents other practical lifestyle advice (pillows to support arm so as not to roll on it, avoid too much activity with affected arm) - “In the meantime, use pillows to support your arm when you sleep sp that you don’t roll on it and try to avoid doing too much activity with your affected arm”
Explains scans not indicated now and only available via hospital - “I understand that you want scans, but at the moment they may not provide much more information that the diagnosis I’ve given you. It’s also only available via the hospital and if I refer you, you may have to wait up to a month before the scans are done.”
Considers shoulder xray (e.g. to exclude OA or calcific tendonitis) - “however, an Xray might still be useful in ruling out other conditions like osteoarthritis and seeing if there is any calcium deposits that is causing your shoulder pain.”
Keep moving shoulder but avoid weights - “It’s important that you continue to move your shoulder to prevent them from getting even stiffer, but avoid lifting any weights”
Decompression surgery not indicated but may referral if conservative measures not helping - “At the moment a decompression surgery may not be necessary, but I can refer you for this is none of the tips I’ve given are helping you”
Additional analgesic such as cocodamol or stronger NSAID (eg naproxen) - “To help with the pain you can also try other painkillers like cocodamol. But one thing to be aware of is that cocodamol can cause constipation.”
Safety-netting
Safetynetting advice (G if two examples) -“If your symptoms aren’t improving within the next week, or you become worried about anything regarding your shoulder, then please come back to the surgery”
Close consultation
“Thank you so much for speaking with me today. Before you go I’d like to give you a patient information leaflet. A great website to go to is NHS choices, which I’ll write on a piece of paper for you to take home with you.”
