Comprehensive Medical Report
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.
PMH:
Childhood illnesses: chicken pox, does not recall other
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.
PMH:
Childhood illnesses: chicken pox, does not recall other