Level 1: Fatigue – Contrasting Case #2: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 29 year old female, presenting to the clinic for recent fatigue and shoulder pain. She is in no acute distress, but is clearly flustered. Her chief complaint is: “I just feel tired all the time and my right shoulder really hurts.”

HPI: Mrs. Mason, a previously healthy 29 year old female, presents to the clinic with complaints of fatigue and right shoulder pain for the past 8 months. She states that approximately 8 months ago she fell on her right shoulder while chasing her 3 year old daughter and hurt her right shoulder. Patient states that she was evaluated at that time for ligament and bone injury. Shoulder radiographs and an MRI of her right shoulder revealed no damage to her soft tissue and joint. However, the patient says that since that time she has continued to have a diffuse, “prickly feeling” over her right shoulder. She denies any radiation of the pain and states that it is a 8/10. Mrs. Mason also reports that the pain often makes her very tired to the point that she is unable to work for a full 8 hours at her job. Nothing seems to make the pain any better and it is typically worse when she becomes upset and when she uses the shoulder for long periods of time.

PMH/FMH: Patient was previously diagnosed with a major depressive disorder, treated successfully with 50mg daily of Zoloft.

SH: Patient works as an accountant at a local marketing firm. She currently lives with her daughter and reports that she is separated from her husband. She states that she will have 2-3 beers a week and between 4-6 on the weekends. Mrs. Mason reports smoking cigarettes on occasion, but states that it is less than one pack per week. No history or current use of illicit drugs.

PE – All within normal limits, except:

Extremities: Examination of the right shoulder reveals good resting muscle tone with no rashes, lesions, or gross deformities. Patient exquisitely tender to palpation over entire right shoulder. Limited range of motion in right shoulder in internal and external rotation due to pain. Examination of left shoulder is unremarkable. Deltoid strength unable to be assessed due to pain upon contact with affected shoulder. All other extremities unremarkable bilaterally.