This is a 20-year-old male patient, who presents to the pain management center today complaining of right shoulder pain. On 08/13/2012, he was playing soccer and fell on his arms outstretched. When he went to get up, his right arm was rotated inwards and he had felt a pop upon injury. He then abducted his right upper extremity with rotation and felt another pop and the shoulder went back into place. He, at this point in time, swelling around the shoulder into the neck and into the axilla and has severely limited range of motion of the right shoulder. He is having pain in the right shoulder joint as well. They rate it at 7-8/10 on a visual analog scale. The pain is aching and sharp in nature. It is constant. Pain is made worse with certain movements and decreased with ice and home remedy therapy that he is using. He has had no treatment otherwise for his symptoms. He is taking ibuprofen which is helping with the pain somewhat. Pain is getting worse.
726.10 Rotator cuff syndrome.
719.41 Joint pain of the right shoulder.
847.0 Cervical sprain.
Clinical findings, assessment, diagnosis, prognosis, and treatment recommendations were discussed with the patient. We will recommend an x-ray of the right shoulder and cervical spine to rule out fracture, dislocation, as well as new injury to the cervical spine. I have recommend MRI of the right shoulder to rule out rotator cuff tear or labral tear given the nature of the dislocation. We also want to rule out any pectoral muscle tear. We will order the patient Naprosyn 500 mg one twice a day for pain and inflammation and Vicodin 5/500 mg one every four to six hours as needed for severe pain, #30 dispensed. I wanted to start physical therapy next week after we get the MRI and x-rays. The patient may need an orthopedic evaluation, but we will get the MRI and x-rays and see what kind of internal pathology is present. The patient has history of hemophilia and in the past he has to take a clotting factor injection following the injuries or prior to any activity that may involve injury. We will recommend he get in contact with his previous treating physicians and/or go to emergency room for further recommendations regarding his hemophiliac related to this injury.