Reason for Visit; s/p ESI X 9 Visits Right Shoulder Strain
S: TM completed total of 9 visits for his right shoulder pain and is here for reevaluation. TM reports his shoulder pain is 2-3/10 at rest and 6-7/10 when he is working. ESI is helpful to manage his pain but the pain is right back, with his current overhead activities at work. TM denies tingling, numbness, or loss of movement in his right side or upper extremities. He takes previously ordered ibuprofen 200 mg 1 tab every 6 hours and Tylenol 500 mg q 8 hours, but not taking them on regular bases.
O: Inspection of the right shoulder no redness or discoloration noted; no tenderness palpation; Full active and passive ROM. Reports increased pain with posterior rotation of his right shoulder;
S: TM completed total of 9 visits for his right shoulder pain and is here for reevaluation. TM reports his shoulder pain is 2-3/10 at rest and 6-7/10 when he is working. ESI is helpful to manage his pain but the pain is right back, with his current overhead activities at work. TM denies tingling, numbness, or loss of movement in his right side or upper extremities. He takes previously ordered ibuprofen 200 mg 1 tab every 6 hours and Tylenol 500 mg q 8 hours, but not taking them on regular bases.
O: Inspection of the right shoulder no redness or discoloration noted; no tenderness palpation; Full active and passive ROM. Reports increased pain with posterior rotation of his right shoulder;