Nicholas Burney H&P 1

Name: N.O.

Age: 59 yo

Address: South Ozone Park

Date and Time: 5/11/21 @ 10:30 AM

CC: Right shoulder pain, follow up

HPI:

59 year old male, right hand dominant, Transportation supervisor, presents for a follow up evaluation for an IOD sustained on 11/22/19 around 9 AM. Patient states he was trying to open a large truck door that is usually supported by spring cables, but he was unaware the cables were broken. He states that as he pulled the handle, the entire weight of the door was pulling against his right arm, which caused him to injure his right shoulder. He states he immediately felt sharp pain in his right shoulder. He denies direct trauma, loss of consciousness, bleeding. He reported the incident to his manager and proceeded to drive himself home. He continued to work with continued right shoulder pain before coming in on 11/29/21 for further evaluation and treatment.

            Today, his right shoulder pain is 5/10, intermittent, radiating down the right arm and up to his neck, sharp with ROM, worse with reaching overhead and when laying on his right side. He reports intermittent numbness and tingling in his right hand.

            Denies fevers, chills and any other complaints.

Patient has been taking ibuprofen 800mg twice a week with relief. He does physical therapy 3 times a week with relief.

Patient has been followed by Orthopedics. He was given a steroid injection in the right shoulder and advised to continue physical therapy. He had a right shoulder arthroscopy on 11/19/20.

He is currently not working due to worsening pain.

 PMH: HTN, Hypothyroidism

PSxH: Right shoulder arthroscopy – 11/19/20

Current meds: Losartan/HCTZ, Synthroid, ibuprofen, Tylenol, Vit C, D3

Allergies: Aspirin – rash

Social : Denies drug and alcohol use, smoking.

PE:

Vitals were not taken during this visit.

General: NAD, well developed, well nourished.

Musculoskeletal: Right shoulder: Healed surgical wound without signs of infection, no edema, ecchymoses, deformities. Tenderness over right shoulder over wounds. Decreased ROM secondary to pain. Drop arm test is negative. Strength 5/5 both upper extremities, grip 5/5 bilaterally.

Neurologic: Gait normal, decreased sensation right 5^th finger.

Skin: No suspicious lesions, skin warm and dry.

Peripheral pulses: +2 bilaterally

Imaging:

MRI Right shoulder – 12/9/19 – supraspinatus tendon tear with mild retraction. Large joint effusion. Hill-sachs deformity. Bicipital tendonitis

Assessment:

Traumatic arthropathy

Strain of muscle and tendon of rotator cuff of right shoulder

Plan:

Orthopedics follow up for continued pain

Dusty status: Not fit for duty

100% temporary disability

Physical therapy, acupuncture 3x a week for 4 weeeks to decrease pain, increase ROM

OTC Tylenol for pain