Reason for Visit: s/p ESI follow up
Vital Signs - B/P: 124/76; Temp: 98.4; Pulse: 70; Resp: 16 O2 Sat 99%
S: TM here for left upper back, left retro upper shoulder pain, recheck after completing ESI. TM rates her pain at 0/10 at rest and 4/10 with repetitive movement. TM completed total of 13 ESI visits. TM reports ESI is very helpful in managing her pain and would like to continue with the ESI. TM reports she is not taking naproxen as ordered and taking ibuprofen and Tylenol, since ibuprofen works better for her than naproxen. TM denies any other issues.
O: Left, retro, upper, shoulder, with enlarged muscle, pain with deep palpation, no edema, warmth, or discolor at the site. Full ROM, neurovascular system intact.
A: Left Shoulder Pain
Vital Signs - B/P: 124/76; Temp: 98.4; Pulse: 70; Resp: 16 O2 Sat 99%
S: TM here for left upper back, left retro upper shoulder pain, recheck after completing ESI. TM rates her pain at 0/10 at rest and 4/10 with repetitive movement. TM completed total of 13 ESI visits. TM reports ESI is very helpful in managing her pain and would like to continue with the ESI. TM reports she is not taking naproxen as ordered and taking ibuprofen and Tylenol, since ibuprofen works better for her than naproxen. TM denies any other issues.
O: Left, retro, upper, shoulder, with enlarged muscle, pain with deep palpation, no edema, warmth, or discolor at the site. Full ROM, neurovascular system intact.
A: Left Shoulder Pain