A Tale of Two Office Visits

This is but one example.  I told my first rheumatologist that my shoulders hurt.

History & Exam

Let’s see you lift your arms over your head.

(painfully lifted arms partially overhead)

Chart Note

shoulders: nl

Dissatisfied, and in increasing pain, I made an appointment with my family physician.

History & Exam

When do they hurt?

They always hurt.  It’s worse with activities such as swimming, volleyball, eating, or hold the steering wheel of the car.  Rolling over at night causes me to awaken in pain.

How long has this been going on?

Off-and-on for a year, but worse for the past few weeks.  One seems to be worse than the other.

What have you tried?  Does anything make it better?

Ibuprofen (800mg) and acetaminophen (1000mg qid) do not help.  Had to hire someone to clean the house weekly because shoulder pain makes some tasks impossible.

Let’s take a look.

Doctor examines each shoulder (separately).  He feels the shoulders as he moves the arms in different directions, even notices wincing.

Chart Note

S:    __ yr old ♀ c/o bilateral shoulder pain
R>L
Intermittent pain x 1yr, worse x3wks
R handed; now sore w/ any motion
No relief w/ ibuprofen 800mg, acetaminophen & plaquenil
Tx’d for RA

O:   NAD*
L shoulder: FROM**
+ crepitus
sore anteriorly & post.
+impingement
R shoulder:  FROM
+ crepitus
sore ant & post
-impingement
previous L shoulder x-ray normal

A:   bilat shoulder RA
r/o rotator cuff tears

P:   1) both shoulders injected with 1cc lidocaine & 1 cc kenalog each by posterior approach
2) R shoulder x-ray
3) Δ mobic 15mg qD #30
4) trial diclofenac gel to shoulders bid
5) RTO x3-4 wks***

Note:  x-rays showed both OA & chronic rotator cuff tendinopathy.  So much for the first doctor’s “normal” shoulder findings without asking any questions or doing an exam.

_________________
*NAD = no apparent distress
**FROM = full range of motion
***RTO = return to office