右肩部痛英文病历－medtrans

Sample History and Physical Note Charting Plus™ - Electronic Medical Records www.medinotes.com converted by http://medtrans.tougao.com require more medical notes / medical records/ medical history/ progressing notes/ medical case/ case report/ admitting notes / dischanrge notes/ case referrence/ 英文病历/ 英语病历 / 病历?>>>please contact medtran@tougao.com Note for John Doe on 6/6/02 - Chart 2646 Chief Complaint: This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The severity has worsened over the past 3 months. Timing (onset/frequency): Onset was gradual and after pitching a baseball game. Modifying Factors: Patient's condition is aggravated by throwing. He participates with difficulty in basketball. Past conservative treatments include NSAID and muscle relaxant medications. Allergies: No known medical allergies. Medication History: None. Past Medical History: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox Past Surgical History: No previous surgeries. Family History: Patient admits a family history of arthritis associated with mother. Social History: Patient denies smoking, alcohol abuse, illicit drug use and STDs. Review of Systems: Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM Psychiatric: (-) psychiatric or emotional difficulties Eyes: (-) visual disturbance or change Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms Allergic / Immunologic: (-) allergic or immunologic symptoms Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat Gastrointestinal: (-) GI symptoms Genitourinary: (-) GU symptoms Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Cardiovascular: (-) cardiovascular problems or chest symptoms Respiratory: (-) breathing difficulties, respiratory symptoms Physical Exam: BP Standing: 116/68 Resp: 16 HR: 68 Temp: 98.1 Height: 5 ft. 11 in. Weight: 165 lbs. Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Oriented to person, place and time. Right shoulder shows evidence of swelling and tenderness. Radial pulses are 2 /4, bilateral. Brachial pulses are 2 /4, bilateral. Appearance: Normal. Tenderness: Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right. Range of Motion: Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation. L shoulder normal. Strength: External rotation - fair. Internal rotation - poor right. AC Joint: Pain with ABD and cross-chest - mild right. Rotator Cuff: Impingement - moderate. Painful arc - moderate right. Instability: None. Test & X-Ray Results: X-rays of the shoulder were performed. X-ray of right shoulder reveals cuff arthropathy present. Impression: Rotator cuff syndrome right. Plan: Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. I noted that this is a very common condition resulting in significant difficulties with use of the arm. Several treatment options and their potential benefits were described. Nonsteroidal anti-inflammatories can be helpful but typically are slow acting. Cortisone shots can be very effective and are quite safe. Often more than one injection may be required. Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear. Injected shoulder joint and with Celestone soluspan 1.0 cc . Ordered x-rays of shoulder right. Prescriptions: Vioxx Dosage: 25 mg tablet Sig: TID Dispense: 60 Refills: 0 Allow Generic: Yes Patient Instructions: Patient was instructed to restrict activity. Patient was given instructions on RICE therapy. _______________________ A. Orthopedist, MD Sample Referral Letter Charting Plus™ - Electronic Medical Records www.medinotes.com 6/6/02 A. General Practitioner, 1231 8th Street, Suite 222 West Des Moines, IA 50265 Dear Dr. General Practitioner: John Doe was seen in my office in consultation as requested by you as a new patient for evaluation and care. The following is a summary of my findings and recommendations: Impression: Rotator cuff syndrome right. Plan: Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. I noted that this is a very common condition resulting in significant difficulties with use of the arm. Several treatment options and their potential benefits were described. Nonsteroidal anti-inflammatories can be helpful but typically are slow acting. Cortisone shots can be very effective and are quite safe. Often more than one injection may be required. Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear. Injected shoulder joint and with Celestone soluspan 1.0 cc . Ordered x-rays of shoulder right. Prescriptions: Vioxx Dosage: 25 mg tablet Sig: TID Dispense: 60 Refills: 0 Allow Generic: Yes Patient Instructions: Patient was instructed to restrict activity. Patient was given instructions on RICE therapy. If I may be of any further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients. Sincerely, A. Orthopedist, MD Sample Patient Instructions Charting Plus™ - Electronic Medical Records www.medinotes.com Patient Instructions for John Doe on 6/6/02 RESTRICTING ACTIVITY ( ) You should significantly restrict activities. ( ) Your activities should be slightly restricted. ( ) You may go about your normal daily routines. ( ) You should not go to work. ( ) You may work with restrictions. ( ) You may work without restrictions. RICE THERAPY RICE stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation. Rest: Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the hand, wrist, elbow, or arm. Continued exercise or activity could cause further injury, increased pain, or a delay in healing. Ice: Ice helps stop bleeding from injured blood vessels and capillaries. Sudden cold causes the small blood vessels to contract. This contraction decreases the amount of blood that can collect around the wound. The more blood that collects, the longer the healing time. Ice can be safely applied in many ways: * For injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. Use ice cubes to keep the water cold, adding more as the ice cubes dissolve. * For injuries to larger areas, use ice packs. Avoid placing the ice directly on the skin. Before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. To make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the cloth. The pack may sit directly on the injured part, or it may be wrapped in place. * Ice the injured area for about 30 minutes. * Remove the ice to allow the skin to warm for 15 minutes. * Reapply the ice. * Repeat the icing and warming cycles for 3 hours. Follow the instructions below for compression and elevation. If pain and swelling persist after 3 hours call our office. You may need to change the icing schedule after the first 3 hours. Regular ice treatment is often discontinued after 24 to 48 hours. At that point, heat is sometimes more comfortable. Compression: Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. Without compression, fluid from adjacent normal tissue seeps into the injured area. To apply compression safely to an injury: * Use an elasticized bandage (Ace bandage) for compression, if possible. If you do not have one available, any kind of cloth will suffice for a short time. * Wrap the injured part firmly, wrapping over the ice. Begin wrapping below the injury site and extend above the injury site. * Be careful not to compress the area so tightly that the blood supply is impaired. Signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. Remove the compression bandage immediately if any of theses symptoms appears. Leave the bandage off until all signs of impaired circulation disappear. Then rewrap the area--less tightly this time. Elevation: Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. Elevate the iced, compressed area in whatever way is most convenient. Prop an injured leg on a solid object or pillows. Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across. _______________________________A. Orthopedist, MD Sample Prescription Charting Plus™ - Electronic Medical Records www.medinotes.com A. Orthopedist, MD DEA#: _____________________________________________________________ Name: Jane Doe Date: 6/6/02 Addr: 1231 8th Street, Suite 222 West Des Moines, IA 50265 _____________________________________________________________ Vioxx 25 mg tablet TID X_____________________________________ X_____________________________________ Substitution Permitted Dispense as written Refills: 0 Disp: 60 Allow Generic: Yes Sample Billing Statement Charting Plus™ - Electronic Medical Records www.medinotes.com Billing Statement - Thursday, June 06, 2002 Provider: A. Orthopedist, MD Patient: John Doe, Chart 2646 1231 8th Street, Suite 222 West Des Moines, IA 50265 Diagnoses 1. 726.10 Disorders Of Bursae And Tendons In Shoulder Region, Unspecified Treatments 1. 20610 Arthrocentesis, Aspiration And/Or Injection; Major Joint Or Bursa (eg, Shoulder, Hip, Knee Joint, Subacromial Bursa) Related Diagnoses: 726.10 Modifiers: Units: 2. 99202 Office or other outpatient visit - new patient - 20 min. Related Diagnoses: 726.10 Modifiers: Units: 3. 73020 Radiologic Examination, Shoulder; One View Related Diagnoses: 726.10 Modifiers: Units: Referring Physician: A. General Practitioner, MD Date Last Seen: 06/12/2001