Comprehensive Medical Report

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  • Topic: Rotator cuff, Physical examination, Humerus
  • Pages : 5 (1137 words )
  • Download(s) : 864
  • Published : March 1, 2012
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Data: 06/03/09

Identifying Data:
Name: J. Smith
Sex: female
Age: 44
Occupation: community college administration assistant
Reliability: good

CC: bilateral shoulder stiffness, right elbow pain

HPI: Ms. Smith presents to the office with bilateral shoulder stiffness and lateral elbow pain in right arm. The patient has been suffering shoulder stiffness for over 2 years. The symptom developed gradually after she started using her computer more at her work place; she had to hold her telephone between her shoulder and head while typing information on computer. The pain in right elbow stated about 8 months ago with gradual onset. The patient does not recall any trauma to the shoulder and elbow. She has been diagnosed as tennis elbow in December 2008 by her chiropractor (Dr. Shui). The patient experiences stiffness on both shoulders, slightly more on the right side. There is no pain with shoulder movement, but she reports tenderness on bilateral trapezius, rhomboid major and minor as well as right rotator cuff muscles upon moderate palpation. She also experiences localized dull, achy pain at lateral epicondyle of right elbow which becomes sharp with mild palpation. There is no pain or paresthesia radiating down to the hands. Mr. Smith experiences the stiffness and pain constantly on a daily basis and rates them a 4 on a 1-10 scale, 1 presenting no pain and 10 presenting extreme pain/stiffness so she cannot move the shoulder or elbow. Keeping one position, such as using computer for a long time, worsens the symptoms. Stretching the shoulder and elbow only briefly alleviates the symptoms. Applying hot pack or taking hot shower also alleviates symptoms. Several massages and physical therapy have been applied and alleviated her symptoms. No antalgic gait, deformity, edema, erythemas, ecchymosis, scars, or muscle spasms are detected. The shoulder ROM and elbow ROM are within normal range.

Childhood illnesses: chicken pox, does not recall other illnesses
Adult illnesses: occasional difficulty falling asleep
Psychiatric illnesses: none reported
Obstetric/Gynecologic history: no pregnancy
Hospitalizations/surgeries: none reported
Injuries/Trauma: none reported
Current medications: women's multivitamin/mineral, 1 tablet, 3 years; Omega-3 fish oil, 650 mg, 1year; OTC sleep aid on occasion to help with sleep
Allergies and drug reaction: no known medication, environmental, and food allergies
Transfusions: none reported
Hazardous exposures: none known

Father: 72, alive and well, no major medical illnesses
Mother: 69, alive and well, no major medical illnesses
Brother: 40, alive and well, no major medical illnesses
No children

SH: Ms. Smith lives with her boyfriend in a condo in San Diego. She was born and raised in Orange County and moved to San Diego with her current boyfriend in 2000. Her parents and brother are still living in Orange County, but she maintains close relations with them. Although she is not considering marriage, Ms. Smith loves her boyfriend a lot and considers him as her best supporter. She has bachelor’s degree in business. She has been working as an administration assistant at community college since 2004, and she likes her job although it occasionally gives her physical/mental stress and leads to insomnia. She denies tobacco, alcohol, or recreational drug use. She is generally a happy person with positive attitude. She is very excited with cooking classes which she is going to take with her boyfriend on Friday nights starting next week.

Diet: 3 meals per day at regular interval with 1 small snack around 3-4 pm; average 1L of
water and 1-2 cups of green tea per day
Exercise: swimming for 1 hour on Mondays and Wednesdays; gym exercise for 1 hour on
Tuesdays and Thursdays; hiking with boyfriend average once a month
Periodic health examination:
Cholesterol: total cholesterol level 165 mg/dL,...
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