CC
William is a 25-year-old male here today to establish care. He would like to talk about right shoulder pain.
HPI
The patient tells me he injured his right shoulder approximately six weeks ago. He reports that he was playing Ultimate Frisbee. He was running forward when someone came in front of him. He tried to jump over that particular person. While doing so, dove forwarded, landed on his right shoulder, and hit his head as well. He did not lose consciousness. This was witnessed by the members of the team, as well as the other team, as well as a nurse who was at the event. He was able to stand up right away. He wanted to keep playing. He reportedly, however, kept repeating what happened to my shoulder and his teammates, at that …show more content…
Medications
He does not take any medications.
Allergies
Amoxicillin
Social History
Single. He lives with some friends. He has no children. He works as a purchasing agent at Service Credit Union, a full time job for him. No tobacco use now or in the past. Alcohol is less than one a week. No drug use now or in the past.
Surgical History
Sinus surgery at 15. He had his adenoids removed as a child.
Family History
Mother is healthy. Father is healthy. He has two brothers. One with splenic mass that was benign. Paternal grandfather deceased of heart disease. Paternal grandmother with history of breast cancer and Alzheimer 's.
His health history questionnaire was reviewed with him here in the office. O
Vital Signs
Temperature: 98.7. BP: 118/70. HR: 78. R: 14. H: 5 '9.5". W: 154. BMI 22.
General
A well-developed well-nourished male no acute distress, seated comfortably in the exam room. He is alert and oriented. He is very pleasant.
HEENT
Pupils equal, round and react to light. Extraocular eye muscles intact. No conjunctival erythema.
Neck
Supple. Full range of motion. No tenderness. No lymphadenopathy
Heart
Regular rate and rhythm. Normal S1, S2. No murmur, rubs, or
William is a 25-year-old male here today to establish care. He would like to talk about right shoulder pain.
HPI
The patient tells me he injured his right shoulder approximately six weeks ago. He reports that he was playing Ultimate Frisbee. He was running forward when someone came in front of him. He tried to jump over that particular person. While doing so, dove forwarded, landed on his right shoulder, and hit his head as well. He did not lose consciousness. This was witnessed by the members of the team, as well as the other team, as well as a nurse who was at the event. He was able to stand up right away. He wanted to keep playing. He reportedly, however, kept repeating what happened to my shoulder and his teammates, at that …show more content…
Medications
He does not take any medications.
Allergies
Amoxicillin
Social History
Single. He lives with some friends. He has no children. He works as a purchasing agent at Service Credit Union, a full time job for him. No tobacco use now or in the past. Alcohol is less than one a week. No drug use now or in the past.
Surgical History
Sinus surgery at 15. He had his adenoids removed as a child.
Family History
Mother is healthy. Father is healthy. He has two brothers. One with splenic mass that was benign. Paternal grandfather deceased of heart disease. Paternal grandmother with history of breast cancer and Alzheimer 's.
His health history questionnaire was reviewed with him here in the office. O
Vital Signs
Temperature: 98.7. BP: 118/70. HR: 78. R: 14. H: 5 '9.5". W: 154. BMI 22.
General
A well-developed well-nourished male no acute distress, seated comfortably in the exam room. He is alert and oriented. He is very pleasant.
HEENT
Pupils equal, round and react to light. Extraocular eye muscles intact. No conjunctival erythema.
Neck
Supple. Full range of motion. No tenderness. No lymphadenopathy
Heart
Regular rate and rhythm. Normal S1, S2. No murmur, rubs, or