Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 1
Return to work & Fit for duty evaluation.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . REVIEW OF SYSTEMS:
Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. MEDICATIONS:
Claritin for allergic rhinitis. ALLERGIES:
None. PHYSICAL EXAMINATION:
Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft.
On examination of the shoulder, he is mild to moderately tender in the posterolateral aspect of the subacromial space. His range of motion is abduction to 90 degrees, before experiencing pain. He can push this to 120 degrees. He also has flexion of 120 degrees but it reluctant to move it past this. He has a very mild response to both Neer's and Hawkins impingement testing. He has negative sulcus, apprehension, Speed's and Yergason's testing. DIAGNOSTIC IMAGING:
Two view x-rays were taken of the shoulder. There are no osseous abnormalities or significant degenerative changes. IMPRESSION:
Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement. PLAN:
The patient is cleared for work. He has the next three days off due to a plant shutdown. Should he have any persistent pain next week, I would considering obtaining an MRI.
consult - history and phy., return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination,
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