In the absence of oseltamivir granules available, adults, adolescents or children who cannot swallow capsules can use this capsule to prepare oral suspension for use.Please follow the method below to make sure the accuracy of dose：1. Hold a 75mg capsule above a small measuring cup. Carefully open the capsule and pour the powder into the measuring cup.     2. Use a calibrated syringe to add 5ml water to the bowl and stir for about 2 minutes.     3. Use syringe to extract the correct amount of mixture (in ml) according to dosage instructed by your doctor from the measuring cup.4. Do not ingest undissolved white powder as these are inactive ingredients. Push the plunger of the syringe and pour the mixture into the second measuring cup. Unused mixtures should be discarded.5. In the second measuring cup, add a small amount (up to 5ml) of sweet food, and mix with the mixture (to cover the bitter taste).6. Mix well and give all to patient. The mixture should be swallowed immediately after preparation. If there is any mixture left in the bowl, rinse with a small amount of water and give to patient to drink.Repeat each time if you need to take the medicine.*Administration instruction (oral)： (1) Oseltamivir can be taken with or without food;Take it with food to relieve stomach discomfort； (2) For the treatment of influenza a and b, treatment should be started within 2 days (ideally within 36 hours) of the onset of flu symptoms.*Storage conditions： ◆ Store in a dry place. Do not store in the bathroom. ◆ Keep all medications in a safe place and out of reach of children and pets.*What do I do if I miss a dose? • Take a missed dose as soon as you think about it. • If it is less than 2 hours until your next dose, skip the missed dose and go back to your normal time. • Do not take 2 doses at the same time or extra doses.Reference:1. Oseltamivir（Tamiflu）Package Insert2. Up to date3. Influenza diagnosis and treatment guide (China 2011)4. Applied Pharmaceutical Practice（2009）

1. Check that the holding chamber is in good condition, without any foreign objects. A damaged holding chamber cannot be used2. Remove the INHALER DEVICE cap3. Shake INHALER DEVICE canister vigorously for about 5 seconds. If using INHALER DEVICE for the first time, shake and spray the INHALER DEVICE into the air 1 to 2 times to ensure that it is in good condition4. Insert the INHALER DEVICE into the back-piece of the holding chamber5. Ask your child to sit in an upright position, and tilt their head back slightly towards the ceiling6. Hold the INHALER DEVICE and holding chamber correctly as shown below7. Apply the mask to your child’s face, ensuring an effective seal around the mouth and nose. Ensure there are no foreign objects in the mouth8. Press the INHALER DEVICE with your thumb to release the medicine9. Ask your child to breathe normally for 10 to 15 seconds, Please do not remove the mask until you have finished 10 to 15 seconds of breathing10. Administer 1 puff at a time. Wait for about 15 to 30 seconds before the next puff.11. Repeat steps 3 to 10 for the next puff12. Remove the mask from the child's face13. Ask your child to rinse his/her mouth, wash their face with water after use and Make sure the child will spit out the mouthwash14. Re-cover INHALER DEVICEHow to clean and store a Valved Holding Chamber：Clean the holding chamber before using it for the first time. Then clean the holding chamber weekly or biweekly1. Remove the parts of the holding chamber (Don't take off your mouthpiece! B1, figure 1)2. Soak the parts for 15 minutes in a mild solution of liquid dish detergent and lukewarm (around 40°C) clean water3. Agitate it gently and clean all parts4. Rinse parts in clean water, if necessary, use tap water to gently flush the one-way valve (B2, figure 1) back to the original position5. Shake out any excess water from the parts, and allow them to air-dry in a vertical position6. Ensure that the parts are dry before reassembly7. Storage temperature: 5°C to 55°C, relative humidity of no more than 90%, cool and clean indoor environmentReference: 1 Chamber insert                   2 Uptodate patient education

Potassium permanganate external solution is used to cleanse wounds and dermatitis skin conditions.Preparation must be freshly made before use. The solution will appear pink or purple in color.Be careful when handling this tablet and solution as it can permanently stain clothing and surface touched.Different concentrations may be used as prescribed by your doctor.Pharmacist to tick √ on the correct concentration for patient according to prescribed strength:○ Concentration 1:10,000 (0.01%)   - Dissolve 1 tablet in 1000ml (1 liter) of warm water   - Sitz bath for topical treatmentInstruction:   - Fill the basin just short of full   - Soak the affected area for 5 to 10 minutes or as directed by your doctor.   - Dry the area with a clean towel that you don’t mind changing color.   - If the solution gets on other areas of your skin, wash with soap and water.○ Concentration 1:4,000 (0.025%)   - Dissolve 1 tablet in 400ml of warm water   - For acute dermatitis, eczema and other skin conditionInstruction:   - Soak the gauze or sterile cotton ball into the prepared solution to apply on the affected skin area as wet dressing.   - The affected area can also be directly soaked into the prepared solution○ Concentration 1:1,000 (0.1%)   - Dissolve 1 tablet in 100ml of warm water   - For wound cleansingInstruction:   - Soak the sterile cotton ball or cotton tip in the prepared solution to clean the affected wound.Warnings1. External use only, do not take orally.2. Irritant to mucosal membranesRef: Product package insert, British National Formulary

Ingredient: Fluconazole 50mg capsule, drinking waterTools: Measuring cup, oral syringe1. Open the 50mg capsule, put the powder content into the measuring cup, and add water until 5ml (to make concentration 10mg/ml).2. Use the oral syringe to measure the correct amount of mixture (dose by bodyweight) as prescribed by doctor:Your child’s dose in prescription: _________mg = ________ml3.Discard the remaining.4. If the child’s treatment dose is more than 50mg, then 150mg capsule will be used, add water to mix to 15ml suspension, repeat 2 and 3.

Step 1: Open• Hold your Accuhaler in one hand with the dose-counter window facing upwards and place the thumb of yourother hand on the thumb grip.• Open your Accuhaler by pushing the thumb grip right around until it clicks.Step 2: Prepare Medication• Hold your Accuhaler level with the mouthpiece towards you.• Use your thumb to push the lever away from you until you hear it clicksStep 3: Breathe out then inhale• Breathe out as much as possible. Avoid exhaling into your Accuhaler• Put the mouthpiece between your teeth and use your lips to seal the mouthpiece• Breathe in steadily with your mouth through your Accuhaler (not through your nose)• Remove your Accuhaler and hold your breath for about 10 seconds• Breathe out slowlyStep 4: Close• Close your Accuhaler by sliding the thumb grip back to the original position until it clicks• Rinse your mouth with water and spit out after using your Accuhaler.• The dose counter on the top of the Accuhaler shows how many doses are left to use. Numbers 5 to 0 will appear in RED, that means you need to get another Accuhaler from doctor.          Click the link for more information on Respiratory Medicine Clinical Service

Warfarin (WAR-far-in) (By mouth)Prevents and treats blood clots. May lower the risk of serious complications after a heart attack. This medicine is a blood thinner.Brand Name(s): Coumadin, JantovenThere may be other brand names for this medicine.When This Medicine Should Not Be Used:This medicine is not right for everyone. Do not use it if you had an allergic reaction to warfarin, if you are pregnant, or if you have health problems that could cause bleeding.How to Use This Medicine:Tablet• Take your medicine as directed. Your dose may need to be changed several times to find what works best for you.• This medicine should come with a Medication Guide. Ask your pharmacist for a copy if you do not have one.• Missed dose: Take a dose as soon as you remember. If it is almost time for your next dose, wait until then and take a regular dose. Do not take extra medicine to make up for a missed dose.• Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.Drugs and Foods to Avoid:Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.• Many medicines and foods can affect how warfarin works and may affect the PT/INR test results. Tell your doctor before you start or stop any medicine, especially the following:   ○ Co-enzyme Q10, echinacea, garlic, ginkgo, ginseng, goldenseal, or St John's wort   ○ Another blood thinner, including apixaban, argatroban, bivalirudin, cilostazol, clopidogrel, dabigatran, desirudin, dipyridamole, heparin, lepirudin, prasugrel, rivaroxaban, ticlopidine   ○ Medicine to treat depression or anxiety, including citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, paroxetine, sertraline, venlafaxine, vilazodone   ○ Medicine to treat an infection   ○ NSAID pain or arthritis medicine, including aspirin, celecoxib, diclofenac, diflunisal, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, mefenamic acid, naproxen, oxaprozin, piroxicam, sulindac. Check labels for over-the-counter medicines to find out if they contain an NSAID.   ○ Steroid medicine, including dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone• Warfarin works best if you eat about the same amount of vitamin K every day. Foods high in vitamin K include asparagus, broccoli, brussels sprouts, cabbage, green leafy vegetables, plums, rhubarb, and canola oil. Talk to your doctor before you make changes to your normal diet.• Do not eat grapefruit or drink grapefruit juice while you are using this medicine.Warnings While Using This Medicine:• It is not safe to take this medicine during pregnancy. It could harm an unborn baby. Tell your doctor right away if you become pregnant. Use an effective form of birth control to keep from getting pregnant during treatment and for at least one month after your last dose.• Tell your doctor if you are breastfeeding, or if you have kidney disease, liver disease, heart disease, diabetes, heart failure, high blood pressure, an infection, a stomach ulcer, or protein C deficiency. Also tell your doctor if you had recent surgery or an injury, or a history of stroke, anemia, severe bleeding or bruising, or problems caused by heparin use.• This medicine may cause the following problems:   ○ Bleeding, which may be life-threatening   ○ Gangrene (skin or tissue damage)   ○ Calciphylaxis or calcium uremic arteriolopathy   ○ Kidney problems, including acute kidney injury   ○ Purple toes syndrome• You must have a PT/INR blood test while you use this medicine to check how well your blood is clotting. Your doctor will use the test results to make sure the medicine is working properly. Keep all appointments for the PT/INR blood tests.• You may bleed or bruise more easily with warfarin. To prevent injury or cuts, do not play rough sports, be careful with sharp objects, and brush and floss your teeth gently. Blow your nose gently, and do not pick your nose.• Carry an ID card or wear a medical alert bracelet to let emergency caregivers know that you use warfarin.•Tell any doctor or dentist who treats you that you are using this medicine. You may need to stop using this medicine several days before you have surgery or medical tests.• Keep all medicine out of the reach of children. Never share your medicine with anyone.Possible Side Effects While Using This Medicine:Call your doctor right away if you notice any of these side effects:• Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing• Bleeding from your gums or nose, coughing up blood, heavy monthly periods• Bleeding that does not stop, bruising, or weakness• Dizziness, fainting, lightheadedness• Pain, brown or black skin, or skin that is cool to the touch• Purple toes or feet, or new pain in your leg, foot, or toes• Purplish red, net-like, blotchy spots on the skin• Red or dark brown urine, or red or black, tarry stools• Vomiting blood or material that looks like coffee groundsIf you notice other side effects that you think are caused by this medicine, tell your doctor.© 2017 Truven Health Analytics LLCClick the link for more information on Emergency Medicine Clinical ServiceClick the link for more information on Cardiovascular Medicine Clinical Service

WHAT YOU NEED TO KNOW:Steri-strips are sterile pieces of medical tape used to close wounds and help the edges grow back together. Steri-strips keep the wound clean and protected while it heals. Steri-strips usually fall off on their own in about 7 to 10 days.DISCHARGE INSTRUCTIONS:Return to the emergency department if:• You have a fever.• You see red streaks on your skin starting at the wound.• Your wound has a foul smell or is draining fluid or pus.• Your wound is red, swollen, and warm to the touch.• Your wound opens or comes apart.Contact your healthcare provider if:• The skin under and around the steri-strips itches or is not comfortable.• You have questions or concerns about your condition or care.How to use steri-strips: Always wash your hands before you care for your wound. This will help prevent infection. Clean and dry the skin around your wound before you put on new steri-strips.• Care for the wound as directed. Do not bathe for 24 hours. After 24 hours, wash around the area gently as directed. Pat the area dry with a clean towel, or let it air dry. Do not rub the area with a towel to dry it. Check the wound for signs of infection, such as swelling or pus.• Only remove the steri-strips if directed. Your healthcare provider may want you to remove the steri-strips after a certain number of days. Do not remove them early, even if they are causing itching or discomfort. If you are directed to remove the steri-strips, pull gently. You might cause the wound to open if you pull hard. Hold the skin down as you slowly and gently remove the strips.• Apply new steri-strips as directed.    ○ Start at the middle of the wound.    ○ Gently bring the edges of the wound together and place the middle of the steri-strip on the wound.    ○ Do not stretch the steri-strip.    ○ Smooth the ends of the steri-strip down onto your skin.    ○ Add more steri-strips as needed for the rest of the wound.    ○ Leave small gaps between strips so you do not completely cover the wound. Fluid from the wound may build under the strips if you completely cover it. The fluid may make the strips peel.    ○ Your healthcare provider may recommend that you add steri-strips down the ends of the pieces you placed across the wound. This will help keep the steri-strips in place as you move.• Do not scrub or pick at the steri-strips. This can cause your wound to open. Trim the edges of the strips if they start to curl. Then press the ends firmly onto your skin.Follow up with your healthcare provider as directed: Write down your questions so you remember to ask them during your visits.© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or Truven Health Analytics.Click the link for more information on Emergency Medicine Clinical ServiceClick the link for more information on Family Medicine Clinical ServiceClick the link for more information on General Surgery Clinical Service

What is hemorrhoid?A hemorrhoid is a swollen vein in the area around the anus, the opening through which stool passes. Hemorrhoids are a very common health problem. Many people have both internal and external hemorrhoids.• Internal hemorrhoids develop inside the anal passageway. They are usually not painful, but they can cause a small amount of bleeding, most often with bowel movements.• External hemorrhoids develop around the rim of the anus, where they can cause itching and discomfort.What are the signs of hemorrhoids?You may see a bit of blood on the toilet paper after having a bowel movement. You might also see traces of blood on your stool or coloring the water inside the toilet bowl. You may feel a bulge or lump in the area around your anus.What causes them?Hemorrhoids can develop from chronic constipation, straining to pass stools, and recurrent diarrhea. Women sometimes get hemorrhoids from pregnancy and childbirth. As you get older, you are more likely to develop hemorrhoids.What is the treatment for hemorrhoids?Although hemorrhoids are annoying, they are not usually a serious medical problem. Most of the time, you can relieve the symptoms of hemorrhoids with home treatments. However, if you notice rectal bleeding, it is important to see your doctor for an examination. Your doctor will check to see whether the bleeding is coming from hemorrhoids or something more serious, such as rectal cancer.Recommended home treatments include:• Increasing the amount of fiber in your diet. A fiber-rich diet softens stools so that they pass more easily, reducing pressure on hemorrhoids   ○ High-fiber foods include beans, broccoli, carrots, bran, whole grains, and fresh fruits. Ask your doctor for patient handouts on dietary fiber and fiber content of foods. To avoid bloating and gas, add these foods gradually over several days. Drinking enough fluids (six to eight cups a day) helps you digest fiber and also helps soften stools.   ○ If you don't think you are getting enough fiber in your diet, you can also buy fiber supplements in the drug store (without a prescription). Flavored and artificially sweetened varieties are available. The usual dose is two teaspoons or two packets in liquid once or twice a day.• Sitz baths. Sitting in a tub filled with warm water for 10 to 15 minutes several times a day can ease discomfort. (Large pharmacies and medical supply stores also sell convenient plastic sitz bath devices that fit into a toilet.) The warm water will keep the area clean, and the warmth will reduce inflammation. Be sure to dry the rectal area thoroughly after each sitz bath. If you work, try taking a sitz bath in the morning, upon your return from work andbefore bedtime.• Applying a cold compress or icepack to the anal area, or try a cool cotton pad soaked in witch hazel.• Petroleum jelly or aloe vera gel, applied to the anal area, can soothe the skin. Over-the-counter hemorrhoid preparations containing hydrocortisone can reduce swelling, but use them sparingly because they can dry out yourskin.If hemorrhoids do not respond to these measures, your doctor may recommend medical treatment.Medical treatments for small to medium, mostly internal hemorrhoids can usually be done in a surgeon’s office. They include:• Rubber-band ligation - A rubber band is slipped around the base of hemorrhoid to cut off its circulation. Once it has been deprived of its vital blood supply, the banded hemorrhoid withers and falls off. This treatment is the most effective and most common.• Sclerotherapy - an irritating chemical solution is injected directly into hemorrhoid or the area around it. The solution interferes with blood flow inside the hemorrhoid, causing it to shrink.• Laser therapy, infrared light therapy, electro-cauterization, or freezing therapy are all used to shrink hemorrhoids.For patients who have large hemorrhoids, or prominent external hemorrhoids, hemorrhoidectomy (surgically removing the hemorrhoids) is sometimes recommended. This procedure is an outpatient procedure done under anesthesia. It usually has excellent results.What can I do to prevent another flare-up of hemorrhoids?• Eat plenty of fiber-rich foods.• Drink plenty of liquids. To help keep your stool soft, it’s a good idea to drink between six and eight glasses of water daily.• Exercise regularly. Twenty to thirty minutes of brisk walking daily helps to stimulate easier bowel movements.• Respond immediately to the urge to have a bowel movement. Do not postpone until the time is more convenient.Home Treatments for HemorrhoidsTo avoid making hemorrhoids worse:• After a bowel movement, blot the area gently with white toilet paper moistened with water. You can also use Baby Wipes or other premoistened towels (such as Tucks) for this purpose.• In the bath or shower, use only soaps without perfumes or dyes. Avoid rubbing the anal area. Gently pat dry with a soft, absorbent, or cloth.To relieve pain and itching:• Apply ice several times a day for 10 minutes at a time. Follow this by placing a warm compress on the anal area for another 10 to 20 minutes.• Take a sitz bath once or twice a day. Sock in a tub or a pan of plain, warm water (at bathwater temperature) for 15 to 20 minutes. You can buy a plastic sitz bath basin that fits into the toilet at larger pharmacies and medical supply stores. The sitz bath water keeps the area clean, decreases redness and swelling, and relaxes the muscles.To prevent hemorrhoids from coming back:• Add more fiber to your diet to prevent constipation. Focus on fruits, vegetables, and whole grains. Fiber supplements such as Citrucel and Metamucil can also add bulk to the diet. You can buy fiber supplements at a drug store without a prescription. They are not laxatives. They do not stimulate the bowel to move. They help make your bowel movements soft and less irritating. Follow the label instructions for use. Be sure to drink plenty of water or other fluids when you increase the fiber in your diet.• Get more exercise. Moderate exercise - 30 minutes or more three or four times a week - helps keep your bowels functioning properly. Brisk walking, swimming, gardening, dancing, housework, any activity that gets you moving will do. Vary the kinds of exercise you do to keep it interesting.This document is intended to provide health-related information so that you may be better informed. It is not a substitute for your care team's medical advice and should not be relied upon for treatment for specific medical conditions.2017 The General Hospital Corporation.Primary Care Office InSiteDeveloped by the MGH Laboratory of Computer Science and Division of General Internal MedicineClick the link for more information on Emergency Medicine Clinical ServiceClick the link for more information on Family Medicine Clinical ServiceClick the link for more information on General Surgery Clinical Service

WHAT YOU NEED TO KNOW:What is a metered-dose inhaler and a spacer?A metered-dose inhaler is a handheld device that gives you a dose of medicine as a mist. You breathe the medicine deep into your lungs to open your airways. A spacer is a tube that attaches to the mouthpiece of your metered-dose inhaler. The spacer helps make your inhaler easier to use. It also helps get the medicine into your lungs better. Your medicine stays in the spacer for a short amount of time. This allows you to breathe one deep breath. You can also breathe in and out at a normal rate up to 5 times. Your healthcare provider will teach you how to use your inhaler and spacer.How do I use my inhaler with a spacer?Practice using your inhaler and spacer. Your medicine will work best if you use them correctly. The steps below will help you use your inhaler and spacer correctly:• Prepare your inhaler and spacer:   ○ Remove the caps from your inhaler and spacer. Check to make sure there is nothing in the mouthpiece that could block the medicine from coming out.   ○ Put the spacer onto the inhaler.   ○ Shake the inhaler to mix the medicine.   ○ Hold the inhaler upright, with the mouthpiece of the spacer pointing towards your mouth.• Get ready to breathe in the medicine:   ○ Keep your mouth away from the mouthpiece, and breathe out fully to clear your lungs.   ○ Place the mouthpiece between your lips. Close your lips around the mouthpiece to form a seal and prevent a medicine leak. If you cannot put your mouth around the mouthpiece, your healthcare provider will give you a spacer with a mask attached. Hold the mask firmly to your face.   ○ Press down the canister and breathe in slowly. This helps the medicine get into your lungs. Make sure to breathe in within 2 seconds of pressing down the canister.   ○ Hold your breath for at least 5 seconds. This will help the medicine reach all parts of your lungs, including the smaller parts called the alveoli.   ○ Breathe out slowly through pursed lips. This helps to keep your airway open and allows the medicine to be absorbed into more areas. Normal 0 false false false EN-US ZH-CN X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:普通表格; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman",serif; border:none;}    ○ Repeat puffs of medicine as directed by your healthcare provider. Wait about 2 minutes between puffs. If you need to use a bronchodilator and a steroid inhaler, use the bronchodilator first. Wait 5 minutes then use the steroid inhaler. Normal 0 false false false EN-US ZH-CN X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:普通表格; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman",serif; border:none;}    ○ Gargle with warm water to remove any leftover medicine from your mouth and throat.How do I care for my inhaler and spacer?Pull your inhaler and mouthpiece apart. Put the caps back on both. Clean your spacer and inhaler at least weekly. Remove the canister from your inhaler before cleaning. Wash your spacer and inhaler with warm soapy water. Rinse and allow to air dry. Make sure both are completely dry before using.When should I seek immediate care?• Your lips or nails turn blue or gray.• The skin between your ribs or around your neck pulls in with every breath.• You feel short of breath, even after you use your inhaler.When should I contact my healthcare provider?• You have to take more puffs from the inhaler than directed, in order to get relief.• You run out of medicine before your next refill is due.• You feel like your medicine is not making your symptoms better.• You have questions or concerns about your condition or care.CARE AGREEMENT:You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.© 2017 Truven Health Analytics LLC All illustrations and images included in CareNotes® are thecopyrighted property of A.D.A.M., Inc. or Truven Health Analytics.Click the link for more information on Emergency Medicine Clinical ServiceClick the link for more information on Family Medicine Clinical ServiceClick the link for more information on Respiratory Medicine Clinical Service

Shoulder pain is a common problem, usually caused by strains and sprains of the soft tissues surrounding the shoulder joint. In most cases, the pain gets better with simple treatments you can do at home.What is shoulder pain?Three bones (the upper arm bone, the shoulder blade, and the collar bone) join to form your shoulder. These bones fit into sockets with cartilage, muscles, and tendons protecting the joints (see image).This structure gives your shoulder a wide range of motion. Pain develops when any of the soft tissues or bony structures are over-extended or injured.What causes shoulder pain?The cause of shoulder pain depends on how the pain began and where it is felt. Acute pain after an injury is usually caused by muscle or tendon strains or tears (most commonly a "rotator cuff injury"). Pain in the shoulder not due to an acute event often begins gradually and may come and go. This type of pain can have many causes, including:• Tendon, ligament or muscle strains• Chronic tears (rotator cuff)• Inflamed bursae (bursitis)• Arthritic changes damaging the cartilage or causing impingement and inflammationFractures of the bones of the shoulder (arm, collar, shoulder blade) are uncommon because it requires significant trauma to break a shoulder bone. However, older people and people with osteoporosis can develop fractures with less trauma.How is shoulder pain treated?Most shoulder pain can be controlled with simple home treatments.• Rest and activity changes:   ○ Avoid any movement that causes pain.   ○ Avoid moving your arm higher than chest level.   ○ Do not lift, carry, or pull heavy objects.   ○ Sleep on the non-painful side with a flat pillow under your armpit to protect the shoulder that hurts.   ○ If recommended, use a sling to immobilize your shoulder for a few days.• Ice:   ○ To help reduce pain and swelling, apply ice (wrapped in a towel or sealed in a plastic bag) 3-5 times a day for 15-30 minutes. Use ice for the first 1-2 days or until pain and swelling subside.• Pain medicine:   ○ In most cases, over-the-counter pain relievers such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve) are enough to control shoulder pain. Prescription medicines are rarely needed and can cause side effects.Do I need X-rays or other imaging tests to help diagnose shoulder pain?It is not in most cases. Your clinician can usually tell what is causing your shoulder pain. He/She can rule out less common causes based on your medical history and physical exam.Does exercise help relieve shoulder pain?The exercise that promotes range of motion and strengthens the shoulder can help speed the healing process. Once pain and swelling begin to ease, you can try a gentle pendulum exercise. The motion shouldn't cause pain (see Figure).Codman (pendulum) exercisesDo this exercise for 5-10 minutes, 3-4 times per day. Move gently at first.• Bend over from the waist• Let the sore arm hang loosely• Swing in forward-back, side-to-side, and circular patterns if this causes pain, stop doing it.Do I need to see a physical therapist or doctor who specializes in shoulder pain?The simple treatments described above help most people get better. People with severe pain and swelling, or symptoms that aren't improving after 2-4 weeks, may be referred to a physical therapist. Most physical therapies are given several times a week for a few weeks with subsequent home exercises.For people with chronic shoulder problems due to arthritis, bursitis, or tendonitis, a steroid shot into the painful area by an orthopedic surgeon or arthritis specialist can provide relief while the natural healing process takes place. For pain that was not improving and thought due to a rotator cuff injury, referral to an orthopedic surgeon is appropriate.What can I do to prevent shoulder pain from coming back?Exercises can help maintain range of motion and strengthen the shoulder muscles.Your clinician can give you instructions for exercises to prevent and treat shoulder pain. Brisk walking and/or swimming are also good activities to help prevent shoulder pain. You can make simple changes in your daily routine, such as:• Avoid tucking your phone between your ear and shoulder when you talk. If you are on the phone a lot, use a headset.• Take frequent breaks at work. Shrug your shoulders up and down. Pull your shoulder blades together, and then relax. Pull your shoulders down while leaning your head to each side to stretch your neck muscles.• Lift and carry the right way. When you are lifting something, bend at your knees, keeping your back neutral, and your head and shoulders up. Avoid carrying bags on one shoulder for a long period. Use a cross-body bag or a backpack-style bag to distribute weight more evenly- and be sure to wear the backpack correctly with both arms through the shoulder loops.This document is intended to provide health-related information so that you may be better informed. It is not a substitute for your care team's medical advice and should not be relied upon for treatment for specific medical conditions.2017 The General Hospital Corporation.Primary Care Office InSiteDeveloped by the MGH Laboratory of Computer Science and Division of General Internal MedicineClick the link for more information on Emergency Medicine Clinical ServiceClick the link for more information on Family Medicine Clinical ServiceClick the link for more information on Orthopaedics and Sports Medicine Clinical ServiceClick the link for more information on Rehabilitation Clinical Service