CC
Mr. Gobbi is a 42-year-old male here today with complaints of left shoulder pain as well as to follow up on his coccyx pain.
HPI
The patient first complained of coccyx pain back in the spring of 2014. He was being active with his kids and fell right onto his coccyx while using a pillowcase to slide down the stairs. He was given an order for an x-ray at that time. Follow up a couple months later, he reported that his pain was better. He chose not to the x-ray. He tells me he is still on and off is having issues with pain in the coccyx. He a few weeks ago was in a golf cart and someone pressed quickly on the gas for the golf cart as he was standing up, causing him to fall back directly onto his tailbone and that seems to have exacerbated the pain and made it worse again. It …show more content…
A/P
Jeffrey Gobbi is a 42-year-old male here today for followup and discussion of left shoulder pain.
Left shoulder pain. The patient had this now ongoing a year and it seems to be getting worse. At this point, we are going to start with an x-ray with potential need for an MRI. Consideration for orthopedics and physical therapy. I will review results of the x-ray with him when they are available. He knows to contact me if he does not hear from me in a timely manner.
Coccydynia. Previously had done well status post an injury now re-injured and it is bothering him again. He is requesting an x-ray order and I gave him an order for that as well. He can continue with using a pillow to sit on or a donut. He could also use Advil as needed.
Type 2 diabetes. He will keep his follow up with Dr. Meattey. So far he seems to be tolerating his new medication. He will update Dr. Meattey if he has any concerns or questions.
Hypogonadism. Currently doing well with his injectable testosterone. Also uses Cialis, if needed. So far that seems to be going well for him and again will keep his follow up with Dr.
Mr. Gobbi is a 42-year-old male here today with complaints of left shoulder pain as well as to follow up on his coccyx pain.
HPI
The patient first complained of coccyx pain back in the spring of 2014. He was being active with his kids and fell right onto his coccyx while using a pillowcase to slide down the stairs. He was given an order for an x-ray at that time. Follow up a couple months later, he reported that his pain was better. He chose not to the x-ray. He tells me he is still on and off is having issues with pain in the coccyx. He a few weeks ago was in a golf cart and someone pressed quickly on the gas for the golf cart as he was standing up, causing him to fall back directly onto his tailbone and that seems to have exacerbated the pain and made it worse again. It …show more content…
A/P
Jeffrey Gobbi is a 42-year-old male here today for followup and discussion of left shoulder pain.
Left shoulder pain. The patient had this now ongoing a year and it seems to be getting worse. At this point, we are going to start with an x-ray with potential need for an MRI. Consideration for orthopedics and physical therapy. I will review results of the x-ray with him when they are available. He knows to contact me if he does not hear from me in a timely manner.
Coccydynia. Previously had done well status post an injury now re-injured and it is bothering him again. He is requesting an x-ray order and I gave him an order for that as well. He can continue with using a pillow to sit on or a donut. He could also use Advil as needed.
Type 2 diabetes. He will keep his follow up with Dr. Meattey. So far he seems to be tolerating his new medication. He will update Dr. Meattey if he has any concerns or questions.
Hypogonadism. Currently doing well with his injectable testosterone. Also uses Cialis, if needed. So far that seems to be going well for him and again will keep his follow up with Dr.