Shoulder Note

Reason for Visit:
Occupation:
Sport:
Involved Side:
Injury:
HPI: 25y/o RHD female with gradually worsening shoulder pain over several years. Severity: 3-7/10. Location: anterolateral shoulder with occasional radiation down lateral arm to deltoid insertion. Duration: gradually worsening over several years. Exacerbating factors: overhead activity, driving. Ameliorating factors: rest, arm at side. Night pain: none. Previous treatment: NSAIDs, no injections, no PT, no surgeries.
PMH:none
PSH:none
Family History: patient questionaire was reviewed in the chart and was signed and dated and is noncontributory.
Medications: none
Allergies: none
SH: no tob, no ETOH, married.
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no metal known metal allergies.
PHYSICAL EXAM
HT: Wt: Pulse:
General Appearance: well-nourished, well-developed, no acute distress. Appears stated age.
Orientation: AO x 3.
Mood / Affect: calm.
Gait: normal.
Skin: normal, no scars bilateral upper extremities.
Lymph: no edema, no lymphadenopathy bilateral upper extremities.
Inspection: shoulders symmetric, no atrophy, no scars bilateral upper extremities.
Palpation: no AC tenderness bilaterally.
Active Forward Elevation (R/L): 160 / 160
Passive Forward Elevation (R/L): 160 / 160
External Rotation at side (R/L): 50 / 50
Internal Rotation (R/L): T9 / T9
Cross Arm (R/L): - / -
Neer (R/L): - / -
Hawkins (R/L): - / -
Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien (R/L): - / -
Yergusons (R/L): - / -
Speeds (R/L): - / -
Sulcus (R/L): - / -
Apprehension (R/L): - / -
Generalized ligamentous laxity: none
C-spine: non-tender, full ROM
Abduction: 5/5 External Rotation: 5/5 Internal Rotation: 5/5
Biceps: 5/5 Triceps: 5/5 Wrist Extension: 5/5 Wrist Flexion: 5/5 Interosseous: 5/5
subjective normal m/u/r/ax sensation
2+ radial pulse
Xray: A/P, scapulolateral, Grashey and Axillary views of the R/L shoulder taken in office today reveal a Type II acromion. The is no os acromionale. The is minimal AC joint space narrowing without sclerosis or osteophyte formation. The greater tuberosity is normal. The glenohumeral joint space is maintained. The glenoid is normal. The scapulohumeral line is maintained. The acromiohumeral space is >7mm.
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
NSAIDS
Information sheet given
Follow-up 6-8 weeks
Patient seen and examined with...