Author: David Liddle, MD
Co Author #1: Amy Powell, M.D., University of Utah Department of Orthopedics
Editor: Jeff Holloway, MD
64 year old right handed tennis player presents with right shoulder and chest pain, fever, and weakness.
The patient is blind in his right eye secondary to a detached retina. One month prior to presentation the patient was playing doubles tennis and could not see his partner coming from the right and the two collided at full speed, forcing his right shoulder posteriorly. He sought no medical therapy and treated his pain with OTC analgesics. Seven days prior to presentation he had acute onset of pain at the right sternoclavicular joint, clavicle, and shoulder; worse with active range of motion or weight bearing. The pain progressed to involve the right chest to the 8th rib and the soft tissues of the arm, chest, and neck. Shoulder series x-rays showed no evidence of fracture. In addition to his pain, he complains of a new course voice with hypophonia. He endorses fevers, chills, & rigors. He denies SOB, dyspnea, LEE, recent surgery, known cancers, recent immobility, or history of DVT. ROS was otherwise negative. He has no significant PMH. He works as a painter but family and social history is otherwise non-contributary.
Temp 38.6, RR 24, HR 105, BP 110/57, SatO2% 85% on room air, Pain 10/10. Moderately ill appearing with dry mucous membranes, JVP 5 cm ARA with patient at 30 degrees, neck ROM limited by pain with induration and erythema overlying the right Sternoclavicular joint and that spreads over the right anterior chest as well as onto the bilateral neck from the larynx to the sternal notch. Cardiovascular, respiratory, and abdominal exams were unremarkable. The right shoulder is tender to palpation (TTP) with pain out of proportion to the stimulus and the right brachium is swollen and TTP.
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