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Shoulder – History

The patient history is the first step in the evaluation of shoulder symptoms. The possible diagnoses will subsequently be confirmed or refuted during the physical examination and radiographic evaluation. Because different pathologies may manifest themselves with similar presenting complaints, with the underlying problem producing only secondary symptoms, assessment of the shoulder is uniquely challenging, and an illuminating history requires the examiner to be well organized and ask specific and focused questions because patients generally do not readily volunteer all necessary information. History will suggest whether a cervical lesion or shoulder lesion is involved.

The examiner should obtain the following information from the patients.

  1. What is the patient age?
  2. Does the patient support the upper limb in a protected position or hesitate to move it?
  3. If there was an injury, what exactly was the mechanism of injury?
  4. Are there any movements or positions that cause the patient pain or symptoms? If so which one?
  5. What is the extent and behavior of patient’s pain?
  6. Are there any activities cause or increase the pain?
  7. Do any positions relieve the pain?
  8. What is the patient unable to do functionally?
  9. How long has the problem bothered the patient?
  10. Is there any indication of muscle spasm, deformity, bruising, wasting, paresthesia or numbness?
  11. Does the patient complain of a feeling of weakness and heaviness in the limb after activity?
  12. Is there any indication for nerve injury?
  13. Which hand is dominant?
  14. what is the patient occupation?