Soap Note x 3 (20 Hours)
Patient: Mr. H, male 54 years old
Hispanic, Spanish
Chief complaint: “I been in pain for the last 3 months with minimal or without relief.”
History of present illness: Mr. H 54 year’s old male came to the office c/o left shoulder pain 8/10 without reliefs since last 3 months. He been taking OTC analgesic without success.
Objective Information Allergies: NKDA.
Social History:
Patient 51 years old male denied smoking, alcohol intake or illicit drugs. Flu Vaccine 10/2019.
Past Medical History:
* Hypertension.
Medications:
* Lisinopril 25 mg PO daily.
Subjective:
Review of Systems:
Constitutional: Denies fever or distress.
Eyes: Denies any eye pain, redness, or tearing. Denies headache.
Ears, Nose, Mouth, and throat: Denies hearing loss or tinnitus or pain. No nasal congestion, drainage, redness, or swelling reported. Denies any throat pain.
Neck: Denies lumps or swollen glands, pain, or neck stiffness.
Cardiovascular: Denies chest pain, SOB or lightheadedness along with any palpitations at this time.
Respiratory: Denies any cough or shortness of breath.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.
Genitourinary: Denies discharge. Denies urgency, dysuria, or hematuria.
Musculoskeletal: Denies joint pain, stiffness, swelling, or muscle pain, other than left shoulder pain for the past 3 months.
Skin: Denies rashes, dryness, color change. No abnormalities of hair or nails.
Neurological: Denies headaches, dizziness, or vertigo. Denies numbness, paresthesias, or tremors.
Mental Health: Denies Psychiatric disorder/ Patient reports good memory and concentration. • Endocrine: Denies endocrine disorder.
Hematologic/Lymphatic: Denies bruising or bleeding. No prior blood transfusions/ No intermittent claudication. Denies leg cramps.
Allergic/Immunologic: No known allergies.
Objective
Physical assessment:
Vital Signs: Temp: 98F B/P (left arm): 131/77 mmHg P: 86bpm R: 19rpm O2 sat: 100% RA Weight: 144lbs High: 5’5” BMI: 24kg/m2
General: Patient AAO x3, well nourished, no acute distress, also denies weight change, fatigue, fever, chills, or night sweats.
Skin:Warm and dry. Good turgor. No surgical scars.
HEENT: No sore throat or earache. No blurry vision or double vision.
Thorax & Lungs:Equal thoracic expansion. Breath sounds clear to auscultation bilaterally, unlabored respirations, no accessory muscle use or retractions. No rhonchi, wheezing, or rales. No tenderness on palpation or percussion of chest wall or spine. Upon percussion, there is tympani bilaterally and symmetrically.
Cardiovascular: No chest pain or palpitations.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.
Abdomen:Soft to palpation, non-distended. No rebound, guarding or tenderness. Bowel sounds present x four quadrants. No hepatic or spleen enlargement. No masses palpated.
Genitourinary: No hematuria or dysuria..
Nervous System:Gross sensation intact. Coordination is intact. Gait is stable and grossly intact.
MS: left shoulder pain. Cap refill <3 seconds. Upper extremities with Radial pulses 2+/4 noted bilaterally, strength testing 5/5 bilaterally, ROM intact. Lower Extremities with Dorsalis pedals pulses 2+/4.
Psych: Patient cooperative, denies history of depression, and anxiety.
Lymphadenopathy: No palpable lymphadenopathies.
Diagnostic Findings:
* Physical examination. * R shoulder x-Ray.
Diagnosis:
* Shoulder osteoarthritis.
Differential diagnoses:
1) Degenerative joint disease.
2) Osteoarthritis.
3) Rheumatoid Arthritis.
Treatment and Educational plan:
1) Ibuprofen 800 mg one tablet q 12 hrs PO PRN if pain.
2) Gabapentin 300 mg twice daily.
3) Proper lifting technique, abdominal wall/core strengthening.
4) Shoulder MRI.
5) Occupational and Physical Therapy to evaluate and treat.
6) Follow up in one week.