MEDICATIONS:
1. Celebrex 100 mg daily.
2. Lasix 40 mg p.r.n.
3. Valium p.r.n.
CHIEF
COMPLAINT: Right shoulder area pain.
HISTORY OF
PRESENT ILLNESS: Patient is complaining
of pain in the right parascapular area and her right shoulder. Sometimes, the pain will radiate down to her
elbow but not below. Patient also has
chronic neck pain. Patient reports that
her symptoms will improve with the use of naproxen. However, this medication was stopped because
of the recent elevation of creatinine, which has since normalized. Minimal pain relief with the use of
Celebrex. Because of the pain in the
right arm, patient is shifting her patient care activities through her left
arm. Patient has pain when she tries to abduct
her right arm in the plain of the scapula.
REVIEW OF
SYSTEMS: No abdominal pain associated
with the use of naproxen. No swelling of
the legs.
PAST MEDICAL
HISTORY: Left mastectomy for breast
cancer. Craniotomy for repair of a Chiari
malformation. Meniscal surgery right
knee. Episode of thrombocytopenia in
2001 prior to removal of breast implants that were placed after mastectomy. Scoliosis of the lumbar spine. Hip dysplasias bilaterally.
PHYSICAL
EXAMINATION:
VITAL
SIGNS: Weight is 262 pounds, blood
pressure 112/74 with a pulse of 87, temperature 98.2.
EXTREMITIES: Range of motion of the shoulders did not appear
to be restricted, however, impingement maneuvers duplicated some of the
patient's symptoms. External rotation of
both shoulders was about 70 degrees and on internal rotation, the patient was
able to get her thumb well over the belt line.
There is no subacromial tenderness on palpation.
IMAGING
STUDIES: I was able to see his shoulders
in the CT scan of the thorax.
Glenohumeral joint spaces were preserved.
LABORATORY
STUDIES: Serum creatinine on May 17th of this year was 1.1 and on June 12th 0.5.
IMPRESSION: Rotator cuff syndrome, right shoulder.
MEDICAL DECISION
MAKING: Ultrasound of the right shoulder
ordered. Patient might consider restarting
Naprosyn.
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