Date:
Patient:
Reason for Visit:
Follow-up for shoulder osteoarthritis (OA)
Assessment of pain and shoulder function
Evaluation of response to treatment (if applicable)
Management plan discussion
History:
Presenting Illness:
Date of initial shoulder OA diagnosis
Location and severity of pain (aching, stiffness, nighttime pain)
Limitation of motion (difficulty reaching overhead, behind the back)
Function limitations due to pain and stiffness (dressing, activities of daily living)
History of injuries or surgeries to the shoulder
Past Medical History (PMH):
Underlying medical conditions that may contribute to OA (e.g., rheumatoid arthritis, diabetes)
Previous treatments for shoulder OA (medications, physical therapy, injections)
Physical Exam:
Inspection:
Observe for posture, symmetry, and swelling around the shoulder joint.
Palpation:
Assess for tenderness at bony prominences and around the joint.
Evaluate for crepitus (grinding sensation) with joint movement.
Range of Motion (ROM):
Measure active and passive ROM of the shoulder joint in all directions (flexion, abduction, internal/external rotation).
Note any limitations in movement due to pain or stiffness.
Neurovascular exam:
Briefly assess sensation, motor function, and pulses in the arm and hand to rule out nerve or vascular compression.
Diagnostic Tests (may be ordered depending on clinical suspicion):
X-ray: Standard imaging to visualize joint space narrowing, osteophytes (bone spurs), and subchondral sclerosis (bone hardening).
MRI (Magnetic Resonance Imaging): May be helpful for evaluating soft tissue damage (e.g., rotator cuff tear) that can coexist with OA.
Ultrasound (less common): Can be used to assess for synovitis (joint inflammation) and bursitis (inflammation of fluid-filled sacs around the joint).
Assessment:
Severity of shoulder OA: Based on X-ray findings, pain level, and functional limitations.
Impact on daily life: Evaluate how OA affects the patient’s ability to perform daily activities and work.
Presence of other shoulder pathology: Consider if rotator cuff tear or other conditions contribute to symptoms alongside OA.
Plan:
Treatment approach based on severity and individual needs:
Non-surgical management:
Pain management: Over-the-counter pain relievers (NSAIDs, acetaminophen), topical analgesics, corticosteroid injections (limited use) for flare-ups.
Physical therapy: Exercises to improve strength, flexibility, and range of motion.
Activity modification: Avoiding activities that aggravate pain, using assistive devices as needed.
Weight management: If overweight or obese, weight loss can reduce stress on the joint.
Surgical intervention (considered for severe cases):
Joint replacement (arthroplasty) or minimally invasive procedures may be options in some patients with advanced OA and significant functional limitations.
Patient education: Provide information about shoulder OA, its progression, and self-management strategies.
Discuss the importance of maintaining a healthy weight and regular exercise.
Explain proper pain medication use and potential side effects.
Instruct on using assistive devices and activity modifications to protect the joint.
Follow-up:
Schedule for follow-up appointments based on disease progression:
More frequent visits for patients with worsening pain or limited function.
Less frequent visits for patients with stable symptoms and good management strategies.
Monitor pain level, function, and response to treatment.
Consider repeat X-rays or imaging if symptoms worsen or new concerns arise.
Discuss the possibility of referral to a physical therapist or orthopedic surgeon for further evaluation and management if needed.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of shoulder osteoarthritis