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