You are a foundation year doctor in A&E. A patient presents with acute shoulder pain following a rugby injury.
1. Take a focused history from the patient.
2. Explain your differential diagnoses and management plan to the examiner.
Checklist
Checklist "MusculoskeletalHistory" not found
Management
Internally Approved
Surname/Nom (1)
Parker
Given names/Prenoms (2)
David
Date of birth/Date de naissance (4)
18 NOV 2002 (22)
Sex/Sexe (5)
m
PRESENTING COMPLAINT
You were playing rugby about an hour ago when you were tackled and fell onto your outstretched right arm. You felt immediate severe pain in your shoulder and couldn't move it. Your shoulder looks different from the other side.
IDEAS, CONCERNS AND EXPECTATIONS
You're worried about whether you'll be able to continue playing rugby this season. You want to know how long recovery will take and if this could happen again.
SYSTEMS REVIEW
Severe right shoulder pain. Unable to move the arm. No numbness or tingling in the hand. No neck pain. No other injuries.
PAST MEDICAL HISTORY
Previous right shoulder dislocation 2 years ago during rugby, reduced in A&E. Otherwise healthy.
DRUG HISTORY
None. No allergies.
FAMILY HISTORY
No relevant family history.
SOCIAL HISTORY
University student. Plays rugby at university level. Lives in student accommodation. Non-smoker. Social alcohol use.
