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Shoulder
Occupation: 
Sports: 
Involved Side:
Date of Injury: none

History of Present Illness
There has been progressive shoulder pain.  It has now progressed to the point that it is limiting daily activities and sleep.

Pain Severity:  5 /10      
Pain location: lateral
Pain at rest:  3/10      
Pain with activity:  7/10      
Ameliorating Factors: rest
Exacerbating factors: activity 
Pain Duration: constant
Pain night: frequent
Previous treatment: activity modifications, icing, nsaids, physical therapy, injections 

Physical Exam:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Shoulder Exam (Bilateral)
Inspection/Palpation UE (R/L): Non-tender bilaterally.
Active FE (R/L): 160 / 160                         Passive FE (R/L): 160 / 160
External Rotation at side (R/L): 45 / 45     Internal Rotation (R/L):
Cross Arm (R/L): neg / neg                       Neer Impingement Test (R/L): neg / neg
Hawkins Test (R/L): neg / neg                  Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien's Test (R/L): neg / neg                 Yergusons Test (R/L): neg / neg
Speeds (R/L): neg / neg                           Apprehension (R/L): neg /neg
Abduction (R/L): 5/5 / 5/5         ER(R/L): 5/5 / 5/5              IR (R/L): 5/5 / 5/5
Biceps (R/L):5/5 / 5/5               Triceps (R/L):5/5 / 5/5       Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median / ulnar / radial / axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally.
UE Skin (R/L): No rashes or lesions.
Lymph UE (R/L): No axillary lymphadenopathy
DTR UE (R/L): Biceps: (2+/2+); Triceps: (2+/2+)
C-spine Flexion: 45                  C-spine Extension: 45
C-spine Right Rotation: 70       C-spine Left Rotation: 70
C-Spine Tenderness: non-tender          Spurling's Test (R/L): neg / neg

Diagnostic Studies
shoulder films form today including Grashe view, supraspinatus outlet view, axillary view and Zanca views were personally evaluated by me and demonstrate:
Acromion: type II 
Acromioclavicular Joint: mild acromioclavicular joint space narrowing with hypertrophic changes in the distal clavicle. 
Glenohumeral joint: the joint space is relatively well preserved
Acromiohumeral interval is greater than 7mm 
Scapulohumeral line is intact.  
Greater tuberosity: mild sclerotic changes 

Assessment

We discussed the natural history and both operative and non-operative treatment options.  We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment.  All questions were answered.  Available links to further peer-reviewed written information on the diagnosis were provided. 

 


ElbowPhysical Exam:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): lateral epicondyle tenderness
ulnar distribution numbness with elbow flexion for >30 seconds.
Lateral epicondyle pain with wrist extension against resistance
Elbow ROM (R/L): 0-130/ 0-130
Suppination (R/L): 80/80Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5                              Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5                Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Lymph UE (R/L): no axillary lymphadenopathy
DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+)

Diagnostic Studies
XRAY ELBOW LEFT
DATE:
PROCEDURE: , 3 VIEWS 
TECHNIQUE: elbow radiographs, AP, oblique and lateral views.
COMPARISONS: None . 
FINDINGS: 
Fracture (s) and/or Dislocation(s): None . 
Alignment: Normal . 
Joint space(s): Normal . 
Soft tissues: Normal . 
Foreign bodies: None . 

 Assessment

 We discussed the natural history and both operative and non-operative treatment options.  We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment.  All questions were answered.  We will begin treatment of the with activity modifications, icing, a counter-force brace, and a naprosyn prescription.  They will follow-up in 4-6 weeks for continued evaluation and management. 

 

Wrist/Hand

Physical Exam
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Wrist / Hand Exam (Bilateral)
Inspection/Palpation (R/L): nontender, no effusion bilaterally
Wrist Flexion_(R/L): 55 / 55                        Wrist Extension_(R/L): 45 / 45
Radial Deviation (R/L):12 / 12                    Ulnar Deviation (R/L): 30 / 30
Hand Function: Able to A-OK, Hook horns, cross fingers, thumbs up bilaterally
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
Wrist Stability (R/L): no instability bilaterally
Wrist Flexion (R/L): 5/5 / 5/5           Wrist Extension (R/L): 5/5 / 5/5 
Intrinsics (R/L): 5/5 / 5/5
UE Skin (R/L): no rashes or lesions bilaterally
Lymph UE (R/L): no axillary lymphadenopathy
DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+)
Tinel's: negative at the carpal tunnel bilaterally

 

Diagnostic Studies
XRAY WRIST LEFT
DATE: 12/29/14
PROCEDURE: 3 VIEWS 
TECHNIQUE:  radiographs, AP, oblique and lateral views.
COMPARISONS: None . 
FINDINGS: 
Fracture (s) and/or Dislocation(s): None . 
Alignment: Normal . 
Joint space(s): Normal . 
Soft tissues: Normal . 
Foreign bodies: None . 

 

Hip Physical Exam

General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Lumbar Spine Exam
Tenderness: none
Flexion: 90
Extension: 30
Lateral Bend(R/L): 30 /30 
Rotation (R/L): 45 / 45
L2 (iliopsoas / mid anterior thigh sensation)= 5/5 : normal
L3 (quadriceps / distal anterior thigh sensation)= 5/5 : normal
L4 (tibialis anterior / patellar reflex / medial ankle sensation)= 5/5 : 2+ : normal
L5 (EHL / dorsal foot sensation)= 5/5 : normal
S1 (Peroneals / Achilles reflex / lateral ankle sensation)= 5/5 : 2+ : normal
No quad tightness
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Seated SLR(R/L): - / -
Supine SLR (R/L): - / -
Dorsalis pedis (R/L): 2+ / 2+
Hip Exam (Bilateral)
Inspection / Palpation LE (R/L): non-tender bilaterally
Hip Flexion (R/L): 120º / 120º               Hip Extension (R/L): 20º / 20º
Hip Adduction (R/L): 15º / 15º             Hip Abduction (R/L): 40º / 40º
Hip IR (R/L): 5º / 5º                              Hip ER (R/L): 30º / 30º
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: Subjective normal distal sensation bilaterally
Vasculature: 2+ dorsalis pedis pulse bilaterally
LE Skin: no rashes or lesions bilaterally
Lymph LE: no inguinal lymphadenopathy
DTR LE: Patellar (2+/2+); Achilles (2+/2+)

Diagnostic Studies
XRAY HIP and PELVIS LEFT
DATE: 12/29/14
PROCEDURE: HIP, 2 VIEWS ; AP Pelvis
TECHNIQUE: hip radiographs, AP and lateral views. AP Pelvis 
FINDINGS: 
Fracture (s) and/or Dislocation(s): None . 
Alignment: Normal . 
Joint space(s): Normal . 
Soft tissues: Normal .

 

Knee Physical Exam 

General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time.    Mood / Affect: calm
Gait: normalCoordination: normal
Knee Exam Bilateral
Inspection / Palpation LE (R/L): non-tender bilaterally 
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature: <2 second capillary bilaterally
LE Skin: no rashes or lesions bilaterally 

 

Diagnostic Studies
Knee films were personally evaluated by me and demonstrate
XRAY KNEE LEFT
DATE: 01/02/15
PROCEDURE: KNEE, 4 VIEWS 
TECHNIQUE: knee radiographs, AP weight bearing, sunrise, Rosenberg and lateral views. 
COMPARISONS: None . 
FINDINGS: 
Fracture (s) and/or Dislocation(s): None . 
Alignment: Normal . 
Joint space(s): Normal . 
Soft tissues: Normal . 
Bone mineralization: Normal . 
Foreign bodies: None . 

 Ankle/Foot Physical Exam

General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Ankle / foot Exam (Bilateral)
Inspection / Palpation LE (R/L): Nontender, no effusion bilaterally
Hindfoot Alignment (R/L):neutral / neutral
Dorsiflexion (R/L): 25º / 25º
Plantarflexion (R/L): 50º / 50º
Anterior Drawer (R/L): PF:(0+/0+), DF:(0+/0+)
Talar Tilt (R/L): Lateral:(0+/0+), Medial:(0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: subjective normal distal sensation bilateral LE
Vasculature: <2 second distal capillary refill bilaterally
LE Skin: No rashes, no lesions
DTR LE: Patellar (2+/2+); Achilles (2+/2+)
Generalized ligamentous laxity: none
Diagnostic Studies
XRAY ANKLE LEFT
PROCEDURE:  3 VIEWS 
DATE: 12/29/14
TECHNIQUE:radiographs, AP, oblique  and lateral views.
FINDINGS: 
Fracture (s) and/or Dislocation(s): None . 
Alignment: Normal . 
Joint space(s): Normal . 
Soft tissues: Normal .  
Foreign bodies: None . 
Cervical 
Physical Exam
Height:           Weight:           Pulse: 80    BP:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Shoulder Exam (Bilateral)
Inspection/Palpation UE (R/L): Non-tender bilaterally.
Active FE (R/L): 160 / 160                         Passive FE (R/L): 160 / 160
External Rotation at side (R/L): 45 / 45     Internal Rotation (R/L): T7 / T7
Cross Arm (R/L): neg / neg                       Neer Impingement Test (R/L): neg / neg
Hawkins Test (R/L): neg / neg                  Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien's Test (R/L): neg / neg                 Yergusons Test (R/L): neg / neg
Speeds (R/L): neg / neg                           Apprehension (R/L): neg /neg
Abduction (R/L): 5/5 / 5/5         ER(R/L): 5/5 / 5/5              IR (R/L): 5/5 / 5/5
Biceps (R/L):5/5 / 5/5               Triceps (R/L):5/5 / 5/5       Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median / ulnar / radial / axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally.
UE Skin (R/L): No rashes or lesions.
Lymph UE (R/L): No axillary lymphadenopathy
DTR UE (R/L): Biceps: (2+/2+); Triceps: (2+/2+)
C-spine Flexion: 45                  C-spine Extension: 45
C-spine Right Rotation: 70       C-spine Left Rotation: 70
C-Spine Tenderness: non-tender          Spurling's Test (R/L): neg / neg
C5 (Deltoid / lateral arm sensation / Biceps)= 5/5 : normal / 2+
C6 (Wrist Extension / Lateral forearm sensation / Brachioradialis)= 5/5 : normal : 2+
C7 (Triceps / Middle finger sensation / Triceps reflex)= 5/5 : normal : 2+
C8 (Interossei / ulnar forearm)= 5/5 : normal
T1 (Interossei / Medial arm)= 5/5+ : normal
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Diagnostic Studies
Cervical spine views were personally evaluated by me and demonstrate mild disc space narrowing at multiple levels.  The alignment is maintained. 
Lumbar
Occupation: 
Sports: none
Involved Side:
Date of Injury: none
History of Present Illness
presents for evaluation of back pain.  Pain has extended past the knee in the past, but does not currently. Pain is 3-7/10. Worse with prolonged walking and any bending or lifting. Pain is 60% low back, 40% thigh. No paresthesia's. No noted weakness. No bowel, bladder or sexual dysfunction. Pain is improved with bedrest. No night pain. no history of immunosuppressive medications. No cancer history. No other joint involvement. 
Pain Severity:   6/10      Pain location: 
Pain at rest: 4/10 Exacerbating factors: activity
Pain with activity:  10/10Ameliorating Factors: rest
Pain Duration: constant
Pain night: 
Previous treatment: activity modifications, icing, nsaids, physical therapy, injections 
Physical Exam
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time.             Mood / Affect: Calm
Gait: normal           Coordination: normal
Skin / Lymph: normal, no scars
Lumbar Spine Exam
Tenderness: none
Flexion: 90
Extension: 30
Lateral Bend(R/L): 30 /30 
Rotation (R/L): 45 / 45
L2 (iliopsoas / mid anterior thigh sensation)= 5/5 : normal
L3 (quadriceps / distal anterior thigh sensation)= 5/5 : normal
L4 (tibialis anterior / patellar reflex / medial ankle sensation)= 5/5 : 2+ : normal
L5 (EHL / dorsal foot sensation)= 5/5 : normal
S1 (Peroneals / Achilles reflex / lateral ankle sensation)= 5/5 : 2+ : normal
No quad tightness
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Seated SLR(R/L): - / -
Supine SLR (R/L): - / -
Dorsalis pedis (R/L): 2+ / 2+
Diagnostic Studies
Lumbar spine films from today were personally evaluated by me and demonstrate mild disc space narrowing with early end plate sclerosis at multiple levels.
Assessment
Plan
We discussed the natural history and both operative and non-operative treatment options.  We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment.  All questions were answered.    We will begin with a course of formal phyiscal theray as well as nsaids and activity modificaitons.  They will follow upin 4-6 weeks for continued care.

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