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HISTORY:
(firstName) presents to the office today for a follow up visit concerning (his_her) {right | left} shoulder symptomatology.
{The patient denies any injuries subsequent to their previous visit. | The patient denies any injuries since their last visit. | The patient denies any injuries subsequent to their initial injury. | The patient notes that there was a new injury since their last visit to this office. {NEW INJURY LOCATION} {NEW INJURY SPECIFIC} | | The patient notes that there was an additional injury subsequent to their initial injury, but prior to today.} {The patient notes that there has been some modest improvement in their condition since the previous visit. | | The patient notes that there has been no improvement in their condition since the previous visit. | The patient notes that there has been no change in their condition since the previous visit. | The patient notes that there has been worsening in their condition since the previous visit. | There has been a complete resolution in the symptoms since the last visit.} {Chiropractic therapy has been continued since the last visit and has been found to be helpful. | Chiropractic therapy has been continued since the last visit but, unfortunately, has not been helpful. | Chiropractic therapy has been discontinued since the last visit. | Physical therapy continues to be undertaken, and has been helpful. | Physical therapy continues to be undertaken, but unfortunately has not been helpful. | Physical therapy has been discontinued since the last visit. | There is no therapy currently being performed. | The patient has been compliant with their therapy program. | The patient has been not been compliant with their therapy program. | The patient has continued therapy with some relief.} {Celebrex is being used, without difficulty, and with good results. | The patient will be changed to Mobic 7.5 mg 1 TAB PO QD. | Celebrex is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with good results. | Ibuprofen has been utilized with good results. | | Anti-inflammatory medications have been discontinued because of gastro-intestinal complications. | Anti-inflammatory medications have not been utilized because of a past history of gastro-intestinal difficulties. | | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Augmentin | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} {The patient has been working. | The patient has been working at full duty. | The patient has been working at full duty, but is having problems with the current work load and needs new restrictions imposed. | The patient is not currently employed, but anticipates starting a new job in the near future. | The patient has been working at light duty, but feel ready to begin unrestricted duty after today's evaluation. | The patient has been working, but at a restricted duty. | The patient has not been working at all.}
{No additional studies are available for today's visit. | The patient presents to the office with MRI films of the left shoulder, which shows evidence of an avulsion fracture of the greater tuberosity at the insertion of the supraspinatous tendon. | The patient presents to the office with MRI films of the right shoulder, which shows evidence of an avulsion fracture of the greater tuberosity at the insertion of the supraspinatous tendon. | The patient presents to the office with MRI films of the right shoulder, which show evidence of impingement and supraspinatous tendonitis. | The patient presents to the office with MRI films of the left shoulder, which show evidence of impingement and supraspinatous tendonitis. | The patient presents to the office with MRI films of the left shoulder, which show evidence of impingement and supraspinatous tendonitis. A full thickness tear is also identified with tendon retraction. | The patient presents to the office with MRI films of the right shoulder, which show evidence of impingement and supraspinatous tendonitis. A full thickness tear is also identified with tendon retraction. | The patient presents to the office with MRI films of the right shoulder, which show no evidence of bone or tendon pathology. | The patient presents to the office with MRI films of the left shoulder, which show no evidence of bone or tendon pathology.}
PHYSICAL EXAMINATION:
{ | The patient's left shoulder range of motion is diminished in all planes of movement. | The patient's right shoulder range of motion is diminished in all planes of movement. | The patient's right shoulder range of motion is normal in all planes of movement. | The patient's left shoulder range of motion is normal in all planes of movement. | The patient's right shoulder range of motion is observed as follows:
Right Shoulder Extension: {ACTIVE-R-SHOULDER-EXT} degrees.
Right Shoulder Flexion: {ACTIVE-R-SHOULDER-FLEX} degrees.
Right Shoulder External Rotation: {ACTIVE-R-SHOULDER EXTERNAL RO | The patient's left shoulder range of motion is observed as follows:
Left Shoulder Extension: {ACTIVE-L-SHOULDER-EXT} degrees.
Left Shoulder Flexion: {ACTIVE-L-SHOULDER-FLEX} degrees.
Left Shoulder External Rotation: {ACTIVE-L-SHOULDER EXTERNAL ROTATI}
{On palpation to the right shoulder, tenderness is noted at the acromioclavicular joint. | On palpation to the left shoulder, tenderness is noted at the acromioclavicular joint. | On palpation to the left shoulder, tenderness is noted at the acromioclavicular joint and the bicep groove. | On palpation to the right shoulder, tenderness is noted at the acromioclavicular joint and the bicep groove. | On palpation to the right shoulder, tenderness is noted at the acromioclavicular joint, bicipital groove, and the anterolateral deltoid. | On palpation to the left shoulder, tenderness is noted at the acromioclavicular joint, bicipital groove, and the anterolateral deltoid. | On palpation to the left shoulder, tenderness is noted at the acromioclavicular joint, bicipital groove, and the anterolateral deltoid. In addition, the patient has a positive Hawkins and Neer's test consistent with impingement syndrome. | On palpation to the right shoulder, tenderness is noted at the acromioclavicular joint, bicipital groove, and the anterolateral deltoid. In addition, the patient has a positive Hawkins and Neer's test consistent with impingement syndrome. | On palpation to the right shoulder, no tenderness is noted. | On palpation to the left shoulder, no tenderness is noted.} {There is no loss of motor strength in either upper extremity. | There is mild loss of motor strength in the right upper extremity. | There is mild loss of motor strength in the left upper extremity. | There is severe loss of motor strength in the right upper extremity. | There is severe loss of motor strength in the left upper extremity. | There is severe loss of motor strength in the right upper extremity with visible atrophy noted in the dorsal interosseous muscles and the thenar eminence. | There is severe loss of motor strength in the left upper extremity with visible atrophy noted in the dorsal interosseous muscles and the thenar eminence.} { | The reflexes in both upper extremities are equal. | There is a diminished brachioradialis reflex in the left upper extremity. | There is a diminished brachioradialis reflex in the right upper extremity. | There is a diminished finger jerk reflex in the right upper extremity. | There is a diminished finger jerk reflex in the left upper extremity. | There is evidence of a hyper-reflexive response in the right upper extremity. | There is evidence of a hyper-reflexive response in the left upper extremity. | There is evidence of a hyper-reflexive response in both upper extremities. | There is a diminished biceps reflex in the right upper extremity. | There is a diminished triceps reflex in the right upper extremity. | There is a diminished triceps reflex in the left upper extremity. | There is a diminished biceps reflex in the left upper extremity. | The patient's reflexes are observed to be non-responsive in both upper extremities.} {There is normal sensation in both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the right upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the left upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the median nerve distribution in the both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the both upper extremities. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the left upper extremity. | There is evidence of decreased sensation to light touch and pin prick along the ulnar nerve distribution in the right upper extremity. | There is diminished sensation in both upper extremities. | There is diminished sensation in the right upper extremity. | There is diminished sensation in the left upper extremity.} { | The vascular status of each upper extremity is within normal limits. | There is diminished vascularity of the right upper extremity. | There is diminished vascularity of the left upper extremity.}
DIAGNOSIS:
{Right Shoulder Impingement Syndrome. | Left Shoulder Impingement Syndrome. | Left Shoulder Rotator Cuff Tendonitis and Bursitis. | Right Shoulder Rotator Cuff Tendonitis and Bursitis. | Right Shoulder Acromioclavicular Joint Arthrosis. | Left Shoulder Acromioclavicular Joint Arthrosis. | Left Shoulder Acromioclavicular Joint Separation, Grade I. | Right Shoulder Acromioclavicular Joint Separation, Grade I. | Right Shoulder Acromioclavicular Joint Separation, Grade II. | Left Shoulder Acromioclavicular Joint Separation, Grade II. | Left Shoulder Acromioclavicular Joint Separation, Grade III. | Right Shoulder Acromioclavicular Joint Separation, Grade III. | Right Shoulder Proximal Humeral Fracture | Left Shoulder Proximal Humeral Fracture | Left Shoulder SLAP lesion. | Right Shoulder SLAP lesion. | Right Shoulder Dislocation. | Left Shoulder Dislocation.}
PLAN:
{It is my recommendation that this patient continue the therapy and medication program currently in progress. | I would recommend that we add a therapy program to the treatment plan at this point in time. | I would recommend that we add anti-inflammatory medications to the treatment program now. | I would recommend that we obtain an EMG of the right upper extremity. | The patient will be scheduled for an MRI of the right shoulder to evaluate for possible rotator cuff pathology. | The patient will be scheduled for an MRI of the left shoulder to evaluate for possible rotator cuff pathology. | The patient was offered a sub-acromial injection into the right shoulder for diagnostic and therapeutic purposes. The patient gave consent and the procedure was performed without problems under sterile condition and the patient reported relief before leav | The patient was offered a sub-acromial injection into the left shoulder for diagnostic and therapeutic purposes. The patient gave consent and the procedure was performed without problems under sterile condition and the patient reported relief before leavi | I would recommend that we obtain an EMG of the left upper extremity. | The patient has been instructed on a general conditioning program consisting focused exercises for the left shoulder. | The patient has been instructed on a general conditioning program consisting focused exercises for the right shoulder.} {I would recommend that there be no limitation in the work activities at this point in time. | I would recommend that this patient be maintained at a light duty work status. | I would recommend that this patient be maintained at a moderate duty work status. | I would recommend that this patient be maintained at a sedentary work status consisting of administrative type task only. | I would recommend that this patient be maintained at a sedentary work status. | Since this patient still has cervical symtomatology, I would recommend that they continue working, but only within their pain tolerance. | The patient is going to attempt a resumption of their current occupation with the understanding the an adjustment in work status may be required if the task prove to be difficult or painful. | I would recommend that the patient try to avoid repetitive overhead work until the right shoulder is asymptomatic. | I would recommend that the patient try to avoid repetitive overhead work until the left shoulder is asymptomatic.} {I have asked this patient to return to the office in 1 week. | I have asked this patient to return to the office in 2 weeks. | I have asked this patient to return to the office in 3 weeks. | I have asked this patient to return to the office in 4 weeks. | I have asked this patient to return to the office in 4 weeks, at which time the patient will likely be placed a MMI. | I have asked this patient to return to the office in 6 weeks. | I have asked this patient to return to the office in 8 weeks.} { | When the patient returns, if no improvement has been noticed the patient will be offered a sub-acromial injection into the right shoulder. | When the patient returns, if no improvement has been noticed the patient will be offered a sub-acromial injection into the left shoulder. | When the patient returns for their next evaluation, they will present with the MRI films for review. Further recommendations will be made at that time depending on the results. | I have asked the patient to keep a mental diary regarding their response to the previous trigger point injections. If the response has been favorable, then additional injections will be offered. | I have asked the patient to keep a mental diary regarding their response to the epidural steroid injections. If the response has been favorable, then additional injections will be offered. | When the patient returns for their next evaluation, treatment considerations will consist of trigger point injections, medicinal magnets, natural relief and diagnostic studies. | When the patient returns for their next evaluation, treatment considerations will consist of a surgical consult regarding chronic pain. | When the patient returns for their next evaluation, treatment considerations will consist of a physical medicine consult regarding chronic pain. | When the patient returns for their next evaluation, treatment considerations will consist of patient education regarding activities to avoid in the future.}
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