Clinical reasoning
How Pathfinder inferred shoulder sub-specialty for Tom Bauer.
CC: Right shoulder pain x 6 weeks, worsening.
HPI: 52 y/o male construction worker presents with progressive right shoulder pain that began after a day of repetitive overhead lifting at a job site. Pain is localized to the anterolateral shoulder, rated 6/10 at rest and 8/10 with overhead motion. Reports difficulty reaching above shoulder height and nighttime pain when sleeping on the affected side. Denies trauma, locking, or instability. Has tried ibuprofen 600mg TID with minimal relief. No prior shoulder injuries or surgeries.
Exam: Right shoulder with tenderness over the greater tuberosity. Active ROM limited in forward flexion (140 degrees) and abduction (130 degrees) due to pain. Rotator cuff weakness noted on resisted external rotation (4/5 strength). Positive Hawkins-Kennedy test. Positive painful arc between 60 and 120 degrees of abduction. Empty can test positive for supraspinatus weakness. Contralateral shoulder exam normal.
Assessment: Clinical presentation consistent with rotator cuff pathology, likely partial-thickness tear given mechanism, duration, and exam findings. Rotator cuff weakness and positive impingement signs warrant further workup.
Plan: Order MRI right shoulder without contrast. Refer to orthopedic surgery, shoulder sub-specialty preferred given suspected rotator cuff tear. Continue NSAIDs, add ice and activity modification. Patient advised to avoid overhead lifting pending evaluation.
No findings related to lower extremity joints. Pain is localized to the shoulder.
No radicular symptoms, no neck or back pain, no neurological deficits.
No distal upper extremity findings. Pain and weakness are proximal.