What is the best approach to prepare a 27-year-old patient with PCOS, plaque psoriasis, and chronic left shoulder pain for a physical exam?

Comprehensive Preparation for Physical Examination of a 27-Year-Old Patient with PCOS, Plaque Psoriasis, and Chronic Left Shoulder Pain

The most effective approach for preparing this 27-year-old patient with multiple conditions requires targeted assessment of each condition with special attention to metabolic, dermatological, and musculoskeletal components.

PCOS Assessment Preparation

History Components to Document

• Onset and duration of signs of androgen excess (hirsutism, acne, alopecia) 1
• Complete menstrual history (regularity, cycle length, amenorrhea) 1
• Medication use including hormonal contraceptives 1
• Lifestyle factors (diet, exercise patterns, alcohol use, smoking) 1
• Family history of cardiovascular disease and diabetes 1
• Psychological impacts (anxiety, depression, body image concerns) 2

Physical Examination Focus

• Distribution of body hair and presence of hirsutism 1
• Presence of acne, balding, or clitoromegaly 1
• Signs of insulin resistance (obesity, acanthosis nigricans) 1
• Blood pressure measurement (hypertension risk) 2
• BMI calculation and waist circumference measurement 2
• Pelvic examination to assess for ovarian enlargement 1

Laboratory Tests to Order

• Fasting glucose level and two-hour oral glucose tolerance test 1
• Total testosterone or bioavailable/free testosterone levels 1
• Thyroid-stimulating hormone level 1
• Prolactin level 1
• Fasting lipid and lipoprotein levels 1

Plaque Psoriasis Assessment Preparation

History Components to Document

• Duration and progression of psoriasis 1
• Previous treatments and responses 1
• Exacerbating factors (stress, medications, climate) 1
• Impact on quality of life and daily activities 1
• Joint symptoms that might suggest psoriatic arthritis 1

Physical Examination Focus

• Document distribution of plaques (elbows, knees, scalp, intertriginous areas) 1
• Assess for inverse psoriasis in body folds 1
• Examine nails for pitting, onycholysis, or other changes 1
• Check for signs of psoriatic arthritis (joint swelling, dactylitis) 1
• Calculate body surface area (BSA) affected 1
• Document Psoriasis Area and Severity Index (PASI) if severe 1

Special Considerations

• Assess for candidiasis in intertriginous areas 1
• Note any correlation between PCOS and psoriasis severity 3, 4
• Women with both PCOS and psoriasis have higher insulin resistance and more severe skin disease 4

Chronic Left Shoulder Pain Assessment Preparation

History Components to Document

• Onset, duration, and progression of pain 5
• Mechanism of injury if applicable 5
• Pain characteristics (location, radiation, aggravating/alleviating factors) 5
• Impact on daily activities and sleep 5
• Previous treatments and their effectiveness 5

Physical Examination Focus

• Compare active and passive range of motion in both shoulders 6
• Perform specific tests based on suspected pathology:
  • Neer and Hawkins-Kennedy tests for impingement (sensitivity 72% and 79%) 6
  • Painful arc test for rotator cuff pathology (specificity 76%) 6
  • Cross-body adduction test for acromioclavicular joint pathology 5
  • Apprehension and relocation tests for instability 5
  • Shoulder shrug sign for stiffness-related disorders 6
• Assess for muscle atrophy or asymmetry 5
• Evaluate neck range of motion to rule out referred pain 5

Imaging Considerations

• Plain radiographs as initial imaging 5
• Consider MRI or ultrasound for suspected rotator cuff disorders 5

Integrated Approach and Special Considerations

• Schedule adequate time for this complex patient with multiple conditions
• Consider metabolic interactions between conditions:
  • PCOS and psoriasis both involve insulin resistance 3, 4
  • Weight management is crucial for both PCOS and may impact psoriasis 2
• Exercise recommendations must account for shoulder pain:
  • Modify exercise recommendations for PCOS (150 min/week moderate intensity) 1, 2
  • Avoid exercises that exacerbate shoulder pain 6
• Mental health assessment is essential as both PCOS and psoriasis impact body image and quality of life 2
• Document medications for all conditions to avoid interactions

Common Pitfalls to Avoid

• Focusing on only one condition while neglecting others
• Failing to recognize the metabolic connection between PCOS and psoriasis
• Not addressing psychological aspects of chronic visible skin disease and PCOS
• Overlooking the potential for psoriatic arthritis in a patient with psoriasis and joint pain
• Neglecting to provide lifestyle recommendations that address both PCOS and psoriasis

By following this comprehensive approach, you will effectively prepare for the physical examination of this complex patient with multiple interrelated conditions.