1-2 PATIENT NOTE: SHOULDER PAIN HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 29 yo male c/o pain in right shoulder. Started 3 days ago after he fell on his right shoulder. Treated at home with ice but the pain persisted. No loss of consciousness after the fall. No paralysis or loss of sensation. Pain in the upper part of the arm increases with movement and is alleviated with rest. The delay in seeking medical assistance is due to the patients work schedule and home responsibilities. Patient is seeking a note for work relief due to right shoulder pain. ROS: negative except as noted above Allergies: NKDA Medications: Tylenol PMH: none, no previous episodes PSH: Appendectomy 10 years ago Fh: Parents alive and well SH: denies tobacco, etoh or drug use, lives with wife and three children, works in construction PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PHYSICAL EXAM GA: Patient is in pain VS: WNL HEENT: normocephalic, atraumatic, no bruises NECK: supple, no bruises CHEST: clear breath sounds bilaterally HEART: RRR, normal S1/S2, no murmers, rubs, or gallops EXTREMITIES: Right shoulder: tenderness over the upper right shoulder, restricted range of motion, unable to assess muscle strength and reflexes due to pain. Right elbow and wrist are normal. Left shoulder: motor 5/5, range of motion: wnl, reflexes: 2/4, left wrist and elbow are normal. Sensation to dull and sharp intact bilaterally, pulses 2/4 bilaterally DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: Shoulder dislocation

HISTORY FINDING(S) - H/o trauma, fell on right shoulder - Pain in the upper arm increased with movement - No paralysis of loss of sensation Diagnosis #2: Rotator cuff injury HISTORY FINDING(S) - H/o trauma - Pain increases with movement - Relieved with rest Diagnosis #3: Humeral fracture HISTORY FINDING(S) - H/o trauma - Pain increases with movement DIAGNOSTIC STUDIES - X-ray right shoulder and arm - MRI shoulder - Bone Density Scan - CBC

PHYSICAL EXAM FINDING(S) - tenderness on right upper shoulder - restricted range of motion

PHYSICAL EXAM FINDING(S) - tenderness on right upper shoulder - restricted range of motion

PHYSICAL EXAM FINDING(S) - restricted range of motion - tenderness on the right upper shoulder