Name: Patil Shankargouda
Age: 47 years old
Sex: male
Occupation: farmer
Marital status: married
Address: Gajapathi, Belagavi
Date of admission: 28/07/21
Date of clerking: 28/07/21
Chief complaint:
Pain at right shoulder since 5 months
HOPI:
The patient came with the complaint of inability to move his right shoulder due to pain since 5
months ago. It was insidious in onset and progressive in nature. Before this, the restriction of
movement due to pain was only a little bit which did not affecting his activity however since one
month back, it is getting worse. He unable to raise his arm due to pain and needed help to do his
activities. He stop going to work one month back due to his problem. The pain is dull aching, and felt
continuously throughout the day and always disturbed his sleep. The pain is localized at the right
shoulder joint only and does not radiate. The pain is aggravated when he try to move his shoulder
and relieved when resting. He came before in KLE hosp one month back and was given medication
(pain killer) however the pain is not reduced. So he came again on 28/07 (2 days back) at KLE hosp.
No history of trauma and swelling.
No history of fever, discharge, sinus, skin injury.
No history of increase pain by the evening, multiple joint pain or morning stiffness of the joint.
No history night sweat, no significant LOW and LOA.
Past medical and surgical history:
No history of DM, HTN, asthma, TB and heart disease. No surgery had done before.
Family history: NIL
Personal history:
Mixed diet, no bad habit. Bladder and bowel habit normal and regular. However, sleep is disturbed
because of pain.
Summary:
A 47 years old male farmer, living in Belagavi came to KLE hospital with the complaint of inability to
move the shoulder due to pain since 5 months which is progressive since one month back. It is not
associated with swelling and trauma.
PHYSICAL EXAMINATION:
General inspection:
The pt was sitting comfortably on bed. He was conscious and well oriented with time, place and
person. He is moderately built and well nourished. He was very cooperative during examination
Vitals:
Pulse: 87bpm
Blood pressure: 120/80 mmhg, left brachial artery, sitting position
Respiratory rate: 18 breaths per min
Temperature: clinically afebrile
Head to toe examination:
PICCKLE: absent
LOCAL EXAMINATION:
Position: the pt is examine in sitting position
Exposure: strip down to the waist
Inspection:
Attitude: The shoulder is internally rotated with adduction, the elbow is flex, the wrist is little bit
dorsi-flex and supinated.
Front:

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no drooping of right shoulder
no deformity of rt shoulder
no prominence of sterno-clavicular and acromio-clavicular joint
no loss of contour of rt shoulder joint
no wasting of deltoid muscle
Behind:

scapula symmetrical and at the same level


no winging of scapula
no supra-spinatus and infra-spinatus muscle wasting
Above:

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Both supraclavicular fossa are not full
No deformity of rt shoulder
no visible swelling
Side:

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the right shoulder is protracted
The shoulder is round
No swelling
No scar
Palpation:
Temperature- no local rise in T
Tenderness- no tenderness
Swelling- no swelling
Bony prominence- NO tenderness, irregularity, broadening, thickening, proximal migration


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humerus head
Greater tubercle
Humerus shaft
coracoid process
Acromion process
Clavicle
Movement: rt shoulder joint
Flexion: (N:180)
Extension: (N: 45)
Adduction (N: 75)
Abduction (N: 180)
Internal rotation ( N: 80)
External rotation (N: 50-90)
Circumduction (N: 360)
Active
40
20
45
45
50
20
40
Passive
40
20
45
45
50
20
40
Measurement:
Length of arm:
Forearm:
Right
34cm
29cm
Left
34cm
29cm
Circumference of arm:
No limb length discrepancy
36cm
There is no muscle wasting
36cm
Special test:
o
Apprehension test: positive. Patient resist due to pain
o
Painful arc test: the patient cannot do due to pain
o
Dugas test: cannot be elicited. The patient able to touch the shoulder however cannot elevate
the arm due to pain
o
Bryant’s sign: negative
o
Callaway’s test: negative. No increase in girth of rt shoulder
o
Hamilton’s test: negative
o
Empty can test: cannot be appreciated due to pain
Neurovascular
All the artery is palpable- axillary artery, brachial artery, radial artery
No lymphadenopathy
Sensory and motor fx intact
Others
Contralateral shoulder joint normal
Ipsilateral elbow and neck joint normal
Other systemic exam: NORMAL
Dx: FROZEN SHOULDER