Clinic note
SUBJECTIVE: A 39-year-old female who complains of 1 week of left shoulder (1)__________. She was riding her motorcycle and doing a lot of work prior to the onset of this. She has tenderness in the muscles of her shoulder and has intermittent (2)__________ with discomfort into the hand. She has not dropped any objects. She does have (3)___________ and thought that she may be having a (4)__________, but was not sure. Patient is otherwise in the usual state of health.
OBJECTIVE: Musculoskeletal: Upper extremities have full range of motion, 5/5 muscle strength. (5)__________ is intact. (6)__________ reflex 2/4. There is tenderness over the left supraspinatus in the scapular area, with muscle spasm of the supraspinatus noted. The (7)__________ musculature is unremarkable. There are no skin changes noted. There is no tenderness of the (8)__________ bursa.
ASSESSMENT/PLAN: Left shoulder musculoskeletal pain with (9)__________. Skelaxin 20 mg 2 t.i.d. to q.i.d., #40. Continue with current Celebrex (10)__________. Warm moist heat. No lifting more than 10 pounds. If no improvement over the next 1 week, return for reevaluation.
1. pain
2. paresthesias
3. lupus
4. flare
5. Neurovascular
6. Brachial
7. rhomboid
8. subacromial
9. spasm
10. regimen
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