CHIEF COMPLAINCE: Left shoulder pain.
HISTORY OF PRESENT ILNESS: The patient is a 66-year male who states
approximately 3 weeks ago, she started developed left shoulder pain mostly located in the
anterior aspect of her left shoulder. He states it is worse with certain types of movements
such as reaching behind his back or head. He states he started playing basketball three
weeks ago however, he has been mostly using his right hand to shoot. She denies any
history of injury or trauma that could have precipitated this. He has been using brufen
400 mcg each day at night, which has been minimally helping with the pain. He states
that with movement, it is five on a scale of ten but at rest, it really does not bother him.
He denies any swelling of the shoulder.
He also has a history of anterior middle sinus mass and right upper lobe nodule on PET
scan in the past. He was supposed to follow up with Dr. Tremmar in Pulmonary;
however, he did not do so. He denies any history of smoking, denies any chest pain,
palpitation or shortness of breath.
He states he had his medications adjusted in regards to his blood pressure by Dr. Leff in
Cartiology. He states he is tolerating the medicines without problems and denies any
lighthness or dizziness. He was having some dizziness at our last visit, but workup
shows a grossly normal 2D echo with a trace LVS with normal ejection fraction and trace
mitral and tricuspid regurgitation. Normal sinus rhythm Holter monitor per Dr. Leff's
note on March and a carotid duplex scan showed less than 50% stenosis bilaterally on
03/15/2007.
He also has hypolipidemia for which he is on Zocor, but denies any myalgias or
weakness taking the medicine.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 81 mg daily. He states he is no longer on Norvasc but
currently on lisinopril 20 mg b.i.d., Zocor 40 mg daily and hydrochlorothiazide 12.5 mg
b.i.d.
PAST MEDICAL HISTORY: Hypertension with hypertensive heart disease with left
ventricular hypertrophy on 2D echocardiogram in 03/2007, hypolipidemia, calcified
mediastinal mass and right upper lobe nodule without a history of smoking.
PAST SURGICAL HISTORY: Foot surgery involving the left foot secondary to a
neuroma and excision. Morton's neuroma removal in right second interspace, right third
proximal interphalangeal joint toe fusion and capsulectomy of the metatarsophalangeal
joints 1, 2, 4 and 5 on 28/28/2007 by Dr. Puhl.
SOCIAL HISTORY: The patient is an engineering technician. The patient admits to
drinking coffee 2 cups a day. The patient denies any tobacco use. The patient does drink
occasionally 2-3 times a week, usually 1 drink per sitting. The patient denies any IV drug
use.
FAMILY HISTORY: Mother alive and well. Father diceased at the age of 18 from a
heart attack. Siblings with diabetes and emmi in their 40s as well as thyroid cancer.
Children none.
REVIEW OF SYSTEMS: As per HPI. The patient denies any chest pain, palpitations,
shortness of breath or abdominal pain.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 110/85, pulse 65, respiratory rate 60, O2 saturation 94%
on room air, pain 5-6 on a scale of 10 in regards to his left anterior shoulder and weight
194.5 pounds.
GENERAL: The patient is a well-developed, well-nourished middle-aged male in no
acute distress.
MUSCULOSKELETAL: No significant tenderness to palpation of the biceps tendon. In
regards to range of motion, the patient had pain with abduction greater than 40 degrees.
He also had pain with external and internal rotation of his left shoulder. He was able to
abduct against resistance without significant pain.
IMPRESSION:
1. Left shoulder pain, most likely secondary to biceps tendonitis. We will be having the
patient do a trial of 40 mg b.i.d. for the next 1 week. We will be also getting an x-ray of
his left shoulder and will be referring him to Rheumatology if the above measures do not
work. I told him not to use any over-the-counter NSAIDs such as ibuprofen, Motrin,
Advil, Aleve or Naprosyn and if he needs any additional pain relief, he can use Tylenol.
2. Hypotension, controlled. The patient to continue with his lisinopril and HCTZ at the
current dosages. The patient will be asking his pharmacy to fax refill request for 3-month
supplies as he states he is somewhat tired getting them monthly.
3. Hyperlipidemia, controlled and stable. The patient to continue with his Zocor at its
current dose.
4. Right upper lobe nodule and caltified anterior mediastinal mass. We will be getting a
CAT scan of his chest with contrast for further evaluation. The patient to make sure he
gets blood work done with a creatinine prior to getting the CAT scan done. We will also
be referring him back to Pulmonary with Dr. Temmar.
The patient to followup in approximately 1 month for an annual physical. I told the
patient if he gets any sort of test done by me and has not heard the results within 2 weeks,
to notify me. The patient understands and agrees with the above plan.