Given the history of trauma directly to the shoulder/neck region and the onset of his symptoms with this traumatic event you may be considering thoracic outlet syndrome, cervical disc/facet involvement and some disorder of the shoulder such as bursitis, tendonitis or even fracture.
Physical Examination Findings: Height = 5’7”, Weight = 150 lbs, Respiration rate = 18, Pulse = 70 and Blood Pressure = 130/85.
Cervical posture shows moderate anterior head carriage with loss of lordosis. Range of motion of the cervical spine was reduced by 25% in left and right rotation with moderate discomfort at end range rotation at the C6/7 levels bilaterally. Cervical joint restrictions were noted C5/6 to C7/T1 bilaterally. Left lateral cervical flexion exacerbated his neck, shoulder and arm pain. Right shoulder range of motion was reduced 25% in abduction and 50% internal/external rotation. Mild soft-tissue swelling was noted along the right supraclavicular and scapular regions extending up to the lateral and posterior aspect of the right side of the neck. No evidence of lymphadenopathy was palpated. Point tenderness was elicited over the greater tuberosity of the right humerus.
Neurological examination revealed decreased sensation to pin wheel following the eighth cervical and first thoracic dermatomes. Intrinsic muscle strength of the right hand was 3/5. Reflexes were normal.
Question 2: Do the examination findings change your differential?
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