Adhesive Capsulitis


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a Foundation Doctor in General Practice

Patient: 45 year old patient has attended with a painful left shoulder

Task:
– Take a focused history from the patient
– After 4 minutes you will perform a focused examination
– After your examination you will be asked a series of questions by the examiner

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

This station includes both history and examination listed below

History
You are a 45 year old women who has presented with worsening left shoulder pain that has been getting gradually worse over the past 2 months. You do not recall any falls or traumatic events to your shoulder. You do not experience any neck, arm, hand pain or alternated sensation. The pain is worst when you move your arm, particularly when you try to move your hands above your head. You are unable to sleep on the left hand side as this brings on the pain.

If asked you are struggling to get dressed by yourself, in particular putting on and off tops. You are also finding it difficult to blow dry and brush your hair.

Past medical history
– Hypothyroidism
– Type 1 diabetic

Drug history
– Thyroxine
– Novorapid insulin
– Lantus insulin
– No known drug allergies

Social history
– You used to smoke when you were younger but you haven’t smoked for 15 years. You used to smoke about 5 per day.

Examination
– You have decreased range of both active and passive range of motion of the left shoulder
– You have forward flection to 60 degrees, abduction to 60 degrees and external rotation to 10 degrees
– Pain is worse at the end of movements
– Rotator cuff strength is normal

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


History History 1
Onset of symptoms
Mechanism of injury
History of trauma or injury


History History 2
Neck pain
Pop or dislocation with injury
Location of pain


History History 3
Radiation of pain
Provoking / alleviating factors
Painful arc (60-120 abduction)
Activities limited


Systems review Systems review
Stiffness
Swelling
Clicking and locking


PMH Past Medical History
Past medical history appropriately explored
Asks about prior shoulder injury or surgery


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately explored


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Examination Look - examination. Comments on:
Swelling
Erythema
Brusing
Atrophy


Examination Feel - examination. Comments on:
Temperature
Palpation (sternoclavicular joint / clavicle / AC joint)


Examination Active movement - examination. Comments on:
Assessment of active movement
Flexion
Extension
Abduction
Internal rotation
External rotation


Examination Passive movement - examination. Comments on:
Assessment as above
Stops if causes pain to patient


Question Given your history and examination what is your most likely diagnosis?
Adhesive capsulitis (If students says frozen shoulder ask what is the medical term for that condition)



Question What is your management plan?
Physiotherapy
NSAID (ibuprofen, naproxen, ect)
PPI cover with NSAID (e.g omeprazole)
2nd line - intra-articular corticosteroid injection
Surgical (uncommon) - arthroscopic capsular release


Question What is the time course of Adhesive Capsulitis
Duration of 9 - 18 hours to run its course
Freezing stage - pain at rest and progressive loss of motion
Frozen stage - rest pain resolves but severely limited motion and pain when reaching
Thawing stage - range of motion returns



Score