HPI: Ms. M is 40 years old and has had shoulder pain for over 6 months. She says the pain began when she fell onto an out-stretched arm (after slipping on ice). She never had it looked at by a doctor, but the pain just got better over the course of several weeks. However, it never got completely better and she continues to have a dull ache in the entire right shoulder. She rates the pain as 3/10 intensity. The pain is worse with activities that require any force with her arm (such as shoveling snow and picking up her 7-year-old daughter). She denies any numbness, tingling, or burning. She does not describe any neck pain or radiating symptoms. She does not take any medications for pain.
Social: No tobacco; no EtOH
On exam, Ms. M is a well-developed female who looks her stated age. BP: 116/80, P: 74, RR: 14. She has 5/5 strength, intact sensation, and 2+ biceps, triceps, and brachioradialis refl exes in her upper extremities bilaterally. Right O’Brien test is positive. Otherwise, she has a negative apprehension test, negative Hawkin, Neer, empty can test, and Speed test on the right. The left shoulder exam is within normal limits. There is no scapular winging bilaterally. 2+ distal pulses are palpated bilaterally.