Michele Czerwinski FNP-S

CASE STUDY

CHIEF COMPLAINT AND HPI

CC: K.M is a 39 year old male present for f/u on labs HPI: K.M. presents today for f/u on labs and is a good

historian and his information is reliable. Denies any discomfort. Reports no changes in his health

status, accidents or hospitalizations since his last visit 11/13 and currently has no specific health concerns at this time .

Denies taking any medication, OTC and denies any herbal or recreational drugs.

PMI

Dyslipidemia, hypercholesterolemia and obesity. Denies any history of respiratory, diabetes, cancer or depression.

Accident/injury: Denies any history of accident or injury. Immunizations: Influenza 2014 and up to date per CDC

guidelines. Medications: Ibuprofen 200 mg tabs II caps PO every 6hrs

PRN ( has not utilized it). Allergies: Denies history of food, seasonal, environmental or

latex allergies.

PMI

Social history: Single and lives in New Hartford. He currently is employed at one of the middle schools in the area as a Spanish teacher.

He does wear a seatbelt when in the car. His exercise consists of weight lifting.

He quit smoking in 2010 and denies being exposed to second hand smoke.

Utilizes alcohol on a weekly basis “one to two drinks” if he goes out. Drinks coffee once a day in the AM. Denies any recreational drugs and being sexually active at this time. Denies any exposure to toxins, pollution or chemicals.

Family history: Parents both positive for hypercholesterolemia and living. Denies history of respiratory, DM or cancer.

REVIEW OF SYSTEMS

Constitutional: Denies nausea, vomiting, fever, chills, night sweats, fatigue, malaise, headache, weight changes, or changes in appetite.

HEENT: Denies blurriness, tinnitus, dysphasia or nasal drainage.

Respiratory: Denies any SOB, wheezing, cough, and dyspnea. Cardiovascular: Denies murmurs, chest pain or palpitations,

dyspnea, edema, orthopnea, shortness of breath upon exertion, syncope or fatigue.

ROS

Cardiovascular: Denies murmurs, chest pain or palpitations, dyspnea, edema, orthopnea, shortness of breath upon exertion, syncope, fatigue or cyanosis .

Gastrointestinal: Denies food intolerances nausea, vomiting, dysphagia, heartburn, epigastric or abdominal pain, flatulence, diarrhea, constipation or changes in bowel movements.

Musculoskeletal: Denies any neck pain or stiffness, joint pain or swelling, back pain, paralysis, weakness, deformities or limitations in ROM.

Integumentary: Denies changes in pigmentation or hair distribution. Denies rashes, eczema, ecchymosis, lesions, moles, changes in nail beds, edema, or other abnormalities.

Neurological: Denies numbness , tingling, dizziness, seizures or tremors.

DIFFERENTIAL DIAGNSOSIS

None injury presents upon elevation of upper extremities ( per MD)

Rhomboid and trapezius muscle rupture Direct injuries to scapulothoracic muscles can cause scapular

winging.

Martin ,R. & Fish ,D. (2007)

PHYSICAL FINDINGS

Constitutional: 98.6-96-20, BP- 130/71, wt. 173 lbs. Ht. 5 ft 8.5 in. BMI 25. 919. Well hydrated, well-nourished male in no acute distress.

HEENT: Normocephalic no evidence of trauma or lesions or pain upon palpation.

PERRLA, bilateral sclera is clear, not injected. The conjunctivas are pink without drainage. External ears clear, no lesions, nodules or drainage. Auricle, pinna and targus non tender to palpation. TM’s pearly gray, light reflex at 5:00 on right and 7:00 on left. Nasal sputum midline. Lips, gingivae, tongue pink and moist without exudate.

Respiratory: Respirations rhythm and depth were symmetrical without retractions and normal rate. LSC to auscultation, no wheezing ,rhonchi or rales heard.

Cardiovascular: S1, S2 regular rate and rhythm. Murmurs present of tricuspid and mitral valves , no rubs, gallops or clicks. No cyanosis noted. Extremities pink, warm, and dry. No peripheral edema and PPP.

PE

Gastrointestinal: Abd soft and round , symmetrical without pulsations, peristalsis, ascites, or discoloration. Umbilicus midline inverted no discharge, odor or erythema. Bowel sounds normal auscultated every 15 seconds in all 4 quadrants. No abdominal bruits elicited. No muscle tightness, referred pain, rebound tenderness, or guarding elicited with palpation. No organmegaly, masses, or hernias. No CVA tenderness.

Neurological: Alert, oriented x three, speech was clear, no seizures, tremors and ROM to all extremities.

Psychiatric: Pleasant and responds appropriately to questions. Smiling and laughing during evaluation.

Musculoskeletal: Posture relaxed. Able to adduct and abduct bilateral upper and lower extremities without discomfort. Dorsiflexion and palmar flexion of present to wrists. Pronation and supination present to elbows. Dorsiflexion and plantar flexion present to right and left ankle without difficulty. Moves all extremities well without guarding or restriction.

DIAGNOSTICS

Basic metabolic panel Lipid profile EGFR Urinalysis

Scapular Winging

When the muscles of the scapula are too weak or paralyzed, resulting in a limited ability to stabilize the scapula.

Paralysis of the serratus anterior following direct trauma of the long thoracic nerve.

The medial border of the scapula protrudes, like wings. The main reasons for this condition are musculoskeletal- and neurological-related.

Physiopedia(2014)

Physiopedia(2014)

Structures Involved

ScapulaM. trapeziusM. serratus anteriorMm.romboideïM.levator scapulaeM. Pectoralis minor M.latissimus dorsiN.accessoriusN.thoracicus longusBrachial plexusPhysiopedia

(2014) & fitfinity (2014)

PATHOPHYSIOLOGY/ETIOLOGY

Acute traumas - direct shock involving the shoulder during a car accident that causes sudden traction on the arm. ( he was trimming hedges in the yard with clippers).

Micro traumas, repeated stretching of the neck in later flexion as in tennis (N. Thoracicus longus) or by wearing a heavy backpack (N. Accessories)

Post-infection, for example an influenza infection Injections Birth defect Post-surgical complications such as chest tube placement Idiopathic causes such as the syndrome of Parsonage and Turner Patients describe a severe or excruciating pain keeping them awake. Most of the

painful scapula alata are caused by a neurological trauma. A winged scapula is not always painful Other patients feel a moderate pain and some are experiencing no pain at all.

Physiopedia(2014)

Acute Injury

Pain ,grating ,snapping –inferior angle of the scapula with shoulder elevation.

Dull ache in shoulder girdle Crepitus with arm elevation Mass at the infero-medial angle with 60 degree abduction

and 30 degree flexion EMG- right long thoracic nerve neuropathy

INCIDENCE

15 cases in 7,000 patients seen –electromyographical One case of serratus anterior paralysis in 38,500 patients

observed at the Mayo Clinic. Three cases of serratus anterior paralysis in a series of

12,000 neurological examinations.

MANAGEMENT/TREATMENT

Rest NSAIDS PT- activate the muscles (ROM) Long-term injection therapy Splint Modified version of the Eden-Lange procedure Scapuloplexy Recovery may take 2 years

REFERENCES

Birrer, R. (1994). Sports medicine for the primary care physician. Boca Raton, FL : CRC.Building An “Anatomy Book” Back http: ( 2014, November 1) Retrieved from fitfinity.net/2012/01/20/building-an-anatomy-book-backMartin ,R. & Fish ,D. (2007). Scapular winging: anatomical review, diagnosis, and treatments. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684151/Physiopedia ( 2014, November 1). Winged scapula. Retrieved from http://www.physiopedia.com/Winged_scapula