ID: Logan Bramey

DOB: 02/21/1974
45 y/o Caucasian Female
Today’s Date: 10/3/2019

CC: “Cough that won’t go away.”

HPI: Ms. Smith is a 47 y/o Female elementary teacher who present complaining of a
cough that has lasted for 1 week. She had a previous fever of 101 degree that was
treated with Ibuprofen and resolved 3 days ago. She endorses a sore throat, runny
nose, and headaches. Pt states she has tried Mucinex for the cough, with no relief. She
is up to date on influenza vaccination (9/12/2019)
Meds:
OTC Ibuprofen
OTC Multivitamin
Allergies:
NKDA, no environmental or herbal allergies noted.
PMHx:
No surgeries or childhood illnesses noted.
Family History:
Mother: age 67 (living) diagnosed with arthritis.
Social History:
Unchanged from prior visit in August 2019
ROS:
General: denies any N/V/D
MSK: denies costochondritis
Physical Exam:
Reviewed VS with pt: BP: 123/85 HR: 72 RR: 14 T: 98.7 deg W: 140 lbs H: 70” BMI:
20.1
General: Pt is AA0x4, WDWN, dressed appropriately for the season, displays mild
discomfort of right shoulder.
Skin: on inspection there is no rashes, masses, or lesions, skin is warm and dry to the
touch.
Pulmonary: LCTAB with no adventitious lung sounds.
Cardio: normal S1/S2 split with RRR, no m/r/g/c, no peripheral edema present, bilateral
radialis pulses 2+ w/RRR, capillary refill of fingers <3 seconds bilaterally.
MSK: inspection reveals normal muscle tone and bulk of arms bilaterally, palpation
reveals no tenderness over acromion, AC joint, clavicle and greater tuberosity. FROM
with active and resisted shoulder abd/add, internal rotation, and external rotation. Neer’s
impingement test positive for pain on right shoulder, positive pain with active shoulder
abduction and flexion.
Radiography:
3 views of the right shoulder were taking in the office today, were read and reviewed,
there are no acute bony abnormalities, fractures, dislocations, or signs of degenerative
changes.
Assessment:
Dx:
1) Shoulder impingement syndrome

Plan:
1) You have been advised to avoid lifting of objects overheads. Please consider
using a step stool to reach high places.
2) You will be referred to physical therapy order and they will help with appropriate
exercises, including at home.
3) Take OTC Aleve as directed by instructions on box for pain and inflammatory
control.
4) You will be referred to orthopedics if your shoulder pain does not subside in 3
months(we can just say this and then type something different)
Follow-up in 4-6 weeks to reassess, if you do not see improvement in your ROM and
strength with PT and OTC aleve we can consider doing a subacromial steroid injection .
However, if pain worsens or any new swelling, redness or warmth in the area, come
back to the clinic sooner.
Steven Congress
PA-S