jwschroeterjr@gmail.com
Guest
- Messages
- 114
- Best answers
- 0
CHIEF COMPLAINT: New 55 year old male patient presents for right shoulder joint pain, left knee pain.HISTORY OF PRESENT ILLNESS; Knee pain. Present for 5 months. Occurred suddenly and notices with new shoes. Reports burning pain. Rated as 6/10 in severity right now and 8/10 in severity all the time. Occurs constantly.REVIEW OF SYSTEMS: Const: Denies shaking chills, fever, night sweats and weight change. General health stated as good. CV: Denies angina, cardiac arrhythmia and hypertension. Resp: Denies productive cough and dyspnea.Gl: Denies hepatitis, reflux and ulcer disease.GU: Urinary: denies dysuria, incontinence and kidney disease. Musculo: Denies poor balance, herniated disc and limitations of movement. Skin: Denies rash and ulcers. Neuro: Denies seizures and stroke. Endocrine: Denies diabetes and thyroid disease.Hema/Lympli: Denies bleeding/clotting disorder and neoplasms.Current Meds: Darvocet N 50 mg; 325 mg, AB Otic DR 54 mg;14 mg, Vicodin Es 7.5 mg;7 50 mg, Prozac 40 mg, Percodan 4.5mg;0.38mg;325mgAllergies: Seafood - Makes Him Cry, Amoxicillin - RashEXAM: Wt Prior: 140 as of 11/16/06 Const: Appears healthy and well developed. Speech is appropriate. Head/Face: Normal on inspection. Facial strength normal. CV: Extremities: No cyanosis, edema or mottling. Musculo:Head/Neck:Insp/Palp: Head is erect. Symmetric. No hypertrophy. Spine:Insp/Palp: Spinal contour is normal. Increased pelvic tilt. Stability: No obvious instability. Knees:Insp/Palp: Left knee normal to inspection and palpation. Right knee normal to inspection and palpation. Stability: No instability in the left. No instability in the right. Normal muscle tone of the left knee. Normal muscle tone of the right knee. ROM: Left knee: full ROM. Right knee: full ROM.Skin: No rashes, lesions or ecchymosis. Neuro: Alert and oriented x3. Displays distrustfulness during encounter. Psych: Patient's attitude is cooperative. Judgment is realistic. Insight is appropriate.ASSESSMENT #1: 719.41 Pain Joint Shoulder RegionPLAN for #1:Xray: Shoulder, One View, RTHPI=Detailed EXAM=Detailed MDM=Low