Shoulder Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 68y/o RHD female with progressive, severe shoulder pain. 7-10/10pain. Complains of crepitus, and decreased motion. Pain and loss of motion has gradually progressed over several-years. Complains of limited function and difficulties with ADL's. + night pain. Previous treatment: NSAIDs, injections, PT without improvement. no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Inspection: shoulders symmetric, no atrophy, no scars
Palpation: no AC tenderness
Active Forward Elevation (R/L): 160 / 160
Passive Forward Elevation (R/L): 160 / 160
External Rotation at side (R/L): 50 / 50
Internal Rotation (R/L): T9 / T9
Cross Arm (R/L): - / -
Neer (R/L): - / -
Hawkins (R/L): - / -
Scapulothoracic motion (R/L): 2:1 / 2:1
C-spine: non-tender, full ROM
Abduction: 5/5 External Rotation: 5/5 Internal Rotation: 5/5
Biceps: 5/5 Triceps: 5/5 Wrist Extension: 5/5 Wrist Flexion: 5/5 Interosseous: 5/5
subjective normal m/u/r/ax sensation
2+ radial pulse
Xray: humeral osteophytes, humeral head flattening, irregular/narrowed joint space, subchondral cystic changes in humeral head, moderate posterior glenoid wear.
MRI: none
ASSESSMENT: Right Shoulder Arthritis (715.11)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Discussed risks of TSA including, but not limited to:Instability / soft tissue imbalance, Rotator cuff tear, ectopic ossification, glenoid loosening, Peri-Prosthetic fracture, nerve injury, infection, humeral loosening, continued pain.
NSAIDS
Information sheet given
Follow-up 6-8 weeks