Betty Miller is a 78-year-old woman who experiences pain in her right shoulder and difficulty with
everyday activities.
Primary Care Visit: Intake
Name: Betty Miller
Age: 78
Gender: Female
Height: 63 years
Weight: 118 pounds
Blood pressure: 120/78
Pulse: 72, regular
Temperature: 98.6 F
Problem: Right shoulder pain, pain medication takes the edge off, general ache in the
right shoulder, difficulty sleeping due to pain, pain with activity like dressing, driving,
activities including quilting, cooking, bathing.
Medication Review
- Metoprolol XL 50 mg daily
- Aspirin 81 mg daily
- Tamsulosin 0.4 mg daily
- Acetaminophen 650 mg every 6 hours as needed
Primary Care Visit: Pain Location
Betty complains about having pain on her right shoulder, stiffness in the right shoulder
even at night: and difficulty with dressing bathing, driving, lifting arm, and lifting objects. The pain is on the front of the shoulder, the back of the right should and over the right shoulder joint.
Primary Care Visit: History
Medical History
Hypertension, pre-diabetes, bladder Issues, osteoarthritis, slightly hard of hearing.
Psychosocial
Betty lives alone. She is a recent widow after caretaking for her spouse for several years. In her home, she has 3 stairs to get into the house and 12 stairs to the basement, where her laundry is located. Both sets of stairs have a side handrail. Her garage is not attached to the house and is located 30 feet from the house. She has reported difficulty in steering her car due to her right shoulder pain, resulting in minor bumps and scraps with her vehicle.
Support
Family
Betty has 2 daughters, one lives close by and another lives 2 hours away. She has good relationships with her daughters. She has 4 grandchildren between the ages of 8 and 22 years of age.
Social Support
Betty has many friends through her community and church. She has lived in this community for many years, she is engaged in a quilting group, engaged in church group and activities at church.
Location
Betty lives in a farmhouse located in rural Iowa. She rents her farmland to a neighbor who lives 1 mile away. She lives 20 minutes from the nearest community but there is no health care available in that community. Her primary care provider and the nearest hospital is located in a community that is a 45 minute drive away.
Hobbies
Betty belongs to a quilting group at church and enjoys quilting at home. She has stopped quilting since the onset of her right shoulder pain. She enjoys spending time with family and friends but she has limited this activity since onset of shoulder pain.
Primary Care Provider – Pain Assessment Tools
At her primary care provider visit, Betty completes two assessment tools:
- Iowa Pain Thermometer Revised (IPT-R) for pain severity
- Pain Enjoyment and General activity (PEG) for a multidimensional assessment of her pain and function
Many older adults prefer use of a verbal descriptor scale with thermometer to express their pain intensity. Each tool provides different information about pain severity and pain impact.
Iowa Pain thermometer scale (Revised) - IPT-R
Betty gave her pain a 6-7 out of 10 on the Iowa Pain Thermometer.
Pain Intensity and Interference- PEG
On the Pain Intensity and Interference Scale, or PEG, Betty scored a 7 on average pain intensity, an 8 on interference with enjoyment of life, and a 7 on interference with general activity, giving her an overall PEG of 7.3 out of 10, or the average of the three individual scores.
Primary Care Provider: Interview
After reviewing Betty’s information, the primary care provider has few questions.
Primary Care Provider – Physical Exam
After reviewing Betty’s information, the primary care provider has few questions.
Palpation Exam
Lungs and Heart Exam
Abdomen Exam
Lower Extremities Exam
Shoulder Exam
Written Summary of Exam
Posture
Increased forward head, increased thoracic kyphosis and increased internal rotation of right shoulder
Neurological
Conversant appropriately. Light touch sensation normal, upper extremity reflexes normal.
Lymph
No palpable nodes, neck supple
Endocrine
Thyroid gland palpable, no nodules.
Lungs
Clear bilateral, no wheezes or rhonchi.
Heart
S1, S2 present, no murmurs, no irregular beats.
Gastrointestinal
Abdomen soft, nontender, no hepatosplenomegaly, and bowel sounds present
Lower extremities
Good strength to abduction, adduction, flexion, extension. Plantar flexion, dorsiflexion equal and strong.
Range of Motion
Neck
Limited range of motion, limited with rotation to left, side bending left
Left upper extremity within functional limits.
Right shoulder with limitations in range of motion for shoulder flexion, abduction, internal and external rotation.
Right elbow and wrist within functional limits.
Strength
Neck, Left shoulder strength within functional limits, right shoulder difficulty to assess due to pain.
Palpation
Moderate guarding in muscle groups surrounding the right shoulder.
Primary Care Visit: Review of Systems Results
Musculoskeletal
- Neck- pain on the right present, thoracic back pain, no lower back pain.
- Legs- mobile, no significant report of weakness, no falls
- Feet- no complaints
Alert, oriented, glasses for vision correction. Good appetite. Swallow fine, slightly hard
of hearing.
Endocrine
Pre-diabetes, blood sugars tested by patient at home. No temperature
changes or weight gain.
Lung
No difficulty
Heart
No chest pain
Gastrointestinal
No reflux nor dyspepsia, bowels with constipation, takes over the counter medication for this once a week
Gynecological
Post menopause with no signs/symptoms of concern
