Soap #2

Blake Renner
S: Chief Complaint: My left shoulder hurts.
Health History: Patient denies any history of neurological disorders,
environmental exposures, family history of neurological disorders or
musculoskeletal conditions, and accidents or trauma to bones/joints. Patient
had two Microdiscectomies for herniated discs (L4/L5 and L5/S1) in
December 2013 and January 2014.
Allergies: No allergies.
Current medications: None
Review of Systems:
Musculoskeletal: Patient denies headache, dizziness/vertigo, seizures,
tremors, weakness, uncoordination, numbness/tingling, or difficulty
swallowing. Patient stated she has left shoulder pain that started 7 months
ago. Pain is aggravated by raising her left arm but, it is not constant. Patient
takes aleeve to relieve pain, but rarely. Pain described as 4 out of 10. Patient
denies stiffness, swelling, heat, redness, limitation of movement,
pain/cramps, weakness, pain, or deformities of the muscles. Patient can
perform all ADLs independently.
O:
Vital signs: BP(sitting, right arm): 130/85. Pulse(radial): 80 BPM.
Respiration(observed): 15 BPM and unlabored. Temp(oral):97.7.
General Survey: Patient is a 27-year-old, Caucasian female. Patient in no
apparent distress and alert. Seems well-nourished and well groomed. Patient
alert and oriented X 4. Facial expression is content. Speech is not slurred.
Mood is appropriate for situation.
Cranial Nerves: III, IV, VI: Palpebral fissure normal. PERRLA and EOMs normal.
VII: No drooping and facial features symmetrical. IX,X: Palate raises
symmetrically.
Musculoskeletal: Upper and Lower extremities have a normal size and are
pink. No swelling, masses, deformity, heat, or tenderness.
Cerebellar Function: Patient can walk on heels, toes, and heel to toe with
accuracy. Romberg test is negative. Coordination and skilled movements are
normal.
Sensory: Patient can accurately determine position, light touch, and vibration
senses on both upper and lower extremities.
Reflexes: Bicep reflex 2 bilaterally. Unable to elicit patellar reflex bilaterally.
No Babinski reflex noted.
A:
Normally developed woman. At risk for pain related to previous surgeries.
Nerve damage related to previous surgeries.
P:

Refer patient for an Orthopedic consult. Encourage patient to participate in

activities that could alleviate her pain and strengthen her shoulder. Refer
patient for Physical Therapy consult.