CHIEF COMPLAINT: The patient came in today complaining of right shoulder pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who came in today complaining of right shoulder pain after bowling approximately 18 hours prior to arrival. The patient does have a history of prior shoulder problems on that right side. The patient was seen by a private physician today for the right shoulder pain and sent here to have an MRI done. The patient complains of pain in the right shoulder with any movement. No edema noted, no crepitus noted. The patient is neurologically intact.
PAST MEDICAL HISTORY:
1. Herniated disk in L4 and 5.
2. Acid reflux.
3. Depression, anxiety.
4. Asthma.
PAST SURGICAL HISTORY: The patient has had a tonsillectomy and adenoidectomy.
CURRENT MEDICATIONS: Birth control.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient smokes probably four cigarettes per day for about the last four years.
FAMILY HISTORY: Asthma.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/78, pulse 76, respirations 18, temperature 97.8, and pulse ox 99% room air.
GENERAL: The patient is alert and oriented x3, in no acute distress noted. The patient was ambulatory in the ED.
SKIN: Warm and dry to touch.
HEENT: Noncontributory to examination.
NECK: Supple without lymphadenopathy. No cervical tenderness with palpation.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmurs, rubs, gallops.
ABDOMEN: Soft, nontender. Positive bowel sounds in all quadrants. No rebound, no guarding, no hepatosplenomegaly. No masses noted.
BACK: Negative for CVA tenderness. No bone tenderness on C-spine through L-spine.
EXTREMITIES: 2+ pulses in all extremities. Full range of motion of left and right lower extremity. On the right shoulder, the patient does have explicit pain with abduction and adduction of right shoulder passive and active movement.
NEUROLOGIC: The patient is alert and oriented x3. The patient has 5/5 strength in all extremities. The patient has 2+ deep tendon reflexes equal throughout extremities. Gross sensation intact.
EMERGENCY DEPARTMENT COURSE: The patient was give a prescription for Vicodin 5 mg, #15. The patient was instructed to take one to two tabs p.o. every four to six p.r.n. pain. The patient was also instructed to take Motrin 600 mg t.i.d. The patient was also placed in a sling and swathe. The patient was instructed to follow up with the private physician for outpatient MRI. The patient was instructed to return to the ED as needed.
MEDICAL DECISION MAKING: We feel this patient is suffering from a long history of right shoulder pain. Etiology is unclear. The patient is scheduled to have an MRI that she will get done outpatient to further investigate right shoulder pain.
DIAGNOSIS: Acute right shoulder pain.
PLAN:
1. The patient was given a prescription for Vicodin 5 mg, #15. The patient was instructed to take one to two tabs p.o. every four to six hours p.r.n. pain.
2. The patient was instructed to take Motrin 600 mg t.i.d. for pain.
3. The patient was instructed to use sling and swathe until seen by private MD and have MRI done.
4. The patient was instructed to use ice for 20 minutes every 4 hours.
5. The patient was instructed to follow up with private MD for outpatient MRI to be done.
6. The patient was instructed to return to ED as needed.
DISPOSITION: This patient was discharged to home in stable condition.
