A complicated shoulder... and a complicated patient

I would like to write a few words about a patient I have been treating over teh past week or so.

A very long and complicated story but essentially he fell onto his shoulder about 5 weeks ago. He has no pain at rest but movement into abduction, and to a lesser extent flexion, is painful and looks pretty average.

My initial feeling was that although we could not perform a thorough Ax due to the high irritability of the patient's injury (and the fact that we had to improvise in treating the patient on a couch in a locked ward!) that there was some joint involvement as PROM was just as painful as AROM. However, we decided to let it be for a few days to see if it would improve before requesting further investigations.

I have seen this patient with 3 different physiotherapists - this has been very interesting to see 3 different approaches, but on the other hand there has been little continuity between sessions, as I have not been doing much of the Rx - I just need to pass information on to the next physio.

After 2 or 3 sessions of fairly vigorous testing, we can't work out exactly what the patient's trouble is, so I am currently in the process of negotiating with the patient's doctors to get some imaging of the shoulder.

This patient is a little more complicated than usual as he has been admitted to this particular facility for an acute episode of his schizophrenia. Our testing of this patient's shoulder involved many, many tests that elicited a pain response, which should be considered in two ways. Firstly, people with schizophrenia generally have a much higher pain threshold than the norm. This worked to our benefit, as we could be fairly confident that if a test was positive (painful) that the patient was feeling 'the pain.' Secondly, and of more concern was the patient's emotional response to us continually causing him pain - the tests were important, but I was wary not to irritate him so that he may become aggressive (common in paranoia).

At each treatment session I get a new piece of information from the patient, particularly about what stresses he has placed his shoulder under since the time of injury. I am not sure if this is because he genuinely didn't think to mention them before, if it is due to a building rapport with him at each session, or if it is due to an improvement in his mental state from new medications (antipsychotics). I am inclined to think it is the second one, or prehaps a combination of all three.

So to summarise, I have drawn a few conclusions:
1) In a facility where no formal detailed physiotherapy notes are written, it is much easier for one therapist to continue with a patient's Rx, rather than 'passing the pipe around'
2) You really need to make a judgement on what you can take from your patient subjectively and what you can't. In this case I was inclined to believe the patient as his story was fairly consistent - new pieces of information were added each time, but if you listened carefully the 'core story' remained the same.
3) And as for judging someones psychological state - I think it has 3 components: experience, reading the notes and then just gut feeling.