| Course | NR 509 Advanced Physical Assessment |
|---|---|
| Week | 3 |
| Paper type | Focused exam write-up |
| Length | About 1,210 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, nurse practitioner core |
| Updated | October 2026 |
Free sample paper for NR 509 Week 3
Focused Shoulder Examination: A 56-Year-Old School Custodian Who Can No Longer Change a Ceiling Light, With a Painful Arc, an External Rotation Lag and the Neck Examined to Rule It Out
Student Name
College of Nursing, Chamberlain University
NR 509: Advanced Physical Assessment
Instructor Name
Month Day, Year
Focused Shoulder Examination: A 56-Year-Old School Custodian Who Can No Longer Change a Ceiling Light, With a Painful Arc, an External Rotation Lag and the Neck Examined to Rule It Out
The Focused History That Justifies the Narrowing
Mr. G. S., 56, a custodian at a middle school, reports right shoulder pain for six weeks. It began after a day spent on a ladder replacing ceiling light tubes along two corridors, and it has not settled. The pain is over the outer upper arm, worse when he lifts his arm to the side or overhead and when he lies on the right side at night. He can no longer hold his arm up long enough to change a light tube and has started asking a coworker to do overhead jobs. He denies neck pain, tingling or numbness in the arm or hand, chest pain, shortness of breath, fever, recent falls or dislocation. He is right-handed. He takes ibuprofen 400 mg as needed, with partial relief. He has hypertension controlled on amlodipine and no diabetes.
The history narrows the question to the shoulder itself, specifically the rotator cuff, because the pain follows repetitive overhead work, is lateral and worse with elevation and at night, and is not accompanied by neck or neurologic symptoms. The two alternatives the examination must address are cervical radiculopathy, which can refer pain to the shoulder, and a cardiac cause, which the history makes unlikely. The examination below examines the shoulder in depth and screens the neck only as far as needed to exclude it.
Inspection and Palpation, in Sequence
Inspection, patient standing, shirt removed, viewed from front, side and back: shoulders level. No swelling, bruising or deformity of the right shoulder. On the right, the supraspinous and infraspinous fossae look flatter than on the left, consistent with wasting of the supraspinatus and infraspinatus. Scapulae symmetric at rest, with no winging on a wall push.
Palpation: Tenderness over the greater tuberosity of the right humerus just below the anterolateral acromion. No tenderness over the acromioclavicular joint, the bicipital groove, the coracoid or the sternoclavicular joint. No warmth. The same points on the left shoulder, checked for comparison, were not tender.
Range of Motion
Active range of motion, right: forward flexion to 150 degrees with pain from about 70 to 120 degrees; abduction to 140 degrees, with pain in the same arc; external rotation at the side 50 degrees; internal rotation behind the back to the level of the lower lumbar spine. Left: flexion 175 degrees, abduction 175 degrees, external rotation 60 degrees, internal rotation to the lower thoracic spine.
Passive range of motion, right: flexion and abduction to 170 degrees, external rotation 60 degrees. The gap between active and passive elevation, with passive motion nearly full, argues against adhesive capsulitis, in which passive external rotation is characteristically lost, and toward weakness or pain limiting active movement.
The System-Specific Maneuvers
Painful arc: Pain on active abduction between 60 and 120 degrees, easing above that range. Positive.
Drop arm test: Arm passively abducted to 90 degrees and released; he lowered it slowly with pain but did not drop it. Negative.
External rotation resistance: Elbow at 90 degrees at his side; resisted external rotation weak on the right, 4/5, and painful. Left 5/5.
External rotation lag sign: Right arm passively placed in near-maximal external rotation with the elbow flexed at the side; when released, the arm drifted back about 15 degrees. Positive. Left: no lag.
Internal rotation (lift-off) test: Able to lift the dorsum of the hand off the lower back against resistance, both sides. Negative.
Empty can (Jobe) test: Arms abducted to 90 degrees in the plane of the scapula, thumbs down; resisted elevation weak and painful on the right. Positive for weakness and pain.
Hawkins-Kennedy and Neer tests: Both reproduced his lateral shoulder pain on the right.
Speed's test and cross-body adduction: No pain. Negative, against biceps tendon and acromioclavicular joint pathology.
Pertinent Negatives, Placed Where They Argue
The negatives that matter here are the ones that rule out the alternatives. Cervical spine: Full, painless neck range of motion; Spurling's maneuver, extension and rotation of the neck toward the right with gentle axial load, did not reproduce arm pain. Neurologic, right upper limb: Biceps, triceps and brachioradialis reflexes 2+ and equal to the left; light touch intact over the lateral arm, forearm and all digits; grip and finger abduction 5/5. These findings argue against cervical radiculopathy. Vascular: Radial pulse 2+ both sides, with no color or temperature difference in the hands. A cardiac cause, already unlikely from the history, is not supported by anything in the examination.
The Findings That Answer the Question
The findings point to rotator cuff disease of the right shoulder, and they suggest a full-thickness tear of the supraspinatus, possibly extending to the infraspinatus. The strength of that conclusion depends on which findings are present. A meta-analysis of the clinical examination for rotator cuff disease found that a positive painful arc was the only pain provocation test with a positive likelihood ratio above 2 for rotator cuff disease, 3.7, and that a positive external rotation lag sign was among the most accurate findings for a full-thickness tear, with a likelihood ratio of 7.2 (Hermans et al., 2013). Mr. G. S. has both, along with weakness of external rotation and supraspinatus testing and visible wasting above and below the scapular spine. The same review cautions that these estimates came from specialists examining referred patients, so their accuracy in a primary care setting is less certain.
Hawkins-Kennedy and Neer tests were positive, but they are sensitive and not specific for cuff pathology, and add little on their own. The negative drop arm test does not exclude a tear.
Assessment: Right shoulder pain with findings consistent with a full-thickness rotator cuff tear, supraspinatus with probable infraspinatus involvement, in a man whose job depends on overhead work; cervical radiculopathy not supported. Plan: Shoulder imaging, with ultrasound or MRI to confirm a full-thickness tear, and orthopedic referral, given that the lag sign and wasting suggest a tear that may benefit from early surgical evaluation in a working man of his age.
What the Examination Could Not Settle
Two questions remain that no maneuver in this examination can answer. The first is the size of the tear and whether the tendon has retracted, which decides whether it can be repaired; the wasting suggests the tear may not be new, and imaging will show how far the muscle has changed. The second is how much of his weakness is pain rather than structural loss. A subacromial injection of local anesthetic followed by repeat strength testing would help separate the two: if external rotation strength returns once the pain is blocked, the weakness is largely pain inhibition; if the lag persists, the tendon is not transmitting force. That test was not done today and is noted for the follow-up visit, so the record shows it was considered.
References
Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L., & Bierma-Zeinstra, S. M. A. (2013). Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA, 310(8), 837-847. https://doi.org/10.1001/jama.2013.276187
The Chamberlain NR 509 Week 3 instructions
The Week 3 assignment asks you to perform a focused examination for a specific complaint and document your findings and reasoning. Plan on covering the focused history, inspection, palpation, range of motion, special tests, pertinent negatives, an assessment and APA. Use the history to justify narrowing to one system. Follow a sequence and record each step with side and position. Compare active and passive range of motion. Name each special maneuver, describe how you did it and report the result. Place pertinent negatives where they rule out alternatives. Weigh tests by how useful they are, not only whether they are positive. Say what the examination cannot answer.
How this NR 509 Week 3 example is built
The history section describes Mr. G. S.'s six weeks of lateral right shoulder pain after overhead work and explains why it points to the rotator cuff. Inspection, with the shirt removed and viewed from three sides, finds no swelling or deformity, and palpation finds tenderness over the greater tuberosity. Range of motion records active flexion to 150 degrees with pain from 70 to 120 and passive flexion to 170. Maneuvers include the painful arc, the drop arm test, resisted external rotation at 4/5, the external rotation lag sign, the lift-off test, the empty can test and Hawkins-Kennedy and Neer tests. Negatives include a painless neck with negative Spurling's. The assessment favors a full-thickness supraspinatus tear. Imaging questions close the paper.
Where the points sit in the NR 509 Week 3 rubric
Focused examination rubrics in NR 509 typically weigh justification for the focus, systematic technique, accurate description of maneuvers, use of pertinent negatives, reasoning in the assessment and APA. The heaviest marks go to reasoning from the findings, and each test is weighed by its usefulness, citing Hermans and colleagues. Focus is credited because the history narrows to the cuff. Technique scores through the inspection, palpation and range of motion sequence. Maneuvers earn points for being described as performed with side and result. Negatives are credited for being placed where they exclude the neck and other joints. Naming what imaging must answer shows limits. Two references complete APA.
NR 509 Week 3 help from the desk
The most common Week 3 loss is an examination that is not actually focused, a general survey relabeled and covering many systems shallowly. Another loss is listing maneuvers by name without saying how they were done or which side. Students also report every positive test as equally meaningful, put pertinent negatives in a separate list where they argue nothing or skip what the examination cannot decide. Focus means one system and one question. Pertinent negatives belong beside the conclusion they support. Report maneuvers that found nothing when they exclude something. Send your complaint and findings, and an NR 509 focused write-up can be organized around one question.
Get a NR 509 Week 3 example written to your instructions
Send the Week 3 instructions, the system your section is examining and your write-up template, and a custom example is written to it inside 24 to 48 hours, first one free. The findings in your own submission have to come from your own examination, and nothing here is submitted on your behalf.
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NR 509 Week 3 questions, answered
How focused is focused? I keep covering too much.
One system, examined to depth, plus only the neighboring findings that bear on it. If a reader cannot tell from the first paragraph which system the document is about, it is not focused yet. Breadth is the most common reason a technically complete Week 3 write-up scores below expectation.
Where should pertinent negatives go?
Beside the findings they qualify rather than collected at the end. A negative placed next to the positive it argues against shows a grader what you were ruling out at that moment. Collected into a closing list, the same negatives read as a checklist rather than as reasoning.
Do I need to report maneuvers I performed that found nothing?
Yes, with their results. A maneuver performed and reported as negative is evidence of thoroughness; the same maneuver left out is indistinguishable from one never attempted. This is the single cheapest way to add defensible depth to a focused write-up. Report it as you would a positive, naming the technique and the side, so the negative reads as a finding rather than an absence.
Where can I find a free NR 509 Week 3 sample paper?
The complete Week 3 focused shoulder examination, with the focused history, sequence, range of motion, special tests, pertinent negatives, the assessment and two references, can be read here.
Which findings point to a rotator cuff tear in the NR 509 Week 3 write-up?
A painful arc, weak and painful resisted external rotation, a positive external rotation lag sign and a weak, painful empty can test on the right side.