Left rotator cuff tendinitis with tear

The patient comes in today for a follow-up visit. He continues to have left shoulder pain and is status post PRP injection. He has had 85% tear of his rotator cuff. He had 30 to 40% improvement of the symptoms with PRP injection. He has undergone physical therapy with improvement. Pain level is 4/10, previously up to 5/10 and currently is 3/10. Currently, he has most of his pain with any type of throwing and any type of motion with his arm. He has not taken any medication at this point. He does ice to the shoulder after his physical therapy. He denies any changes in his past medical history, past surgical history, medication history, family history, social history, or review of systems.

DIAGNOSES:
Left rotator cuff tendinitis with tear.
Osteoarthritis of the shoulder.
Shoulder joint pain.

RECOMMENDATIONS:
We will continue physical therapy three times a week for more weeks. If he still has persistent pain, then we would recommend repeating a second PRP injection. He has seen some improvement with therapy. He is having improved strength in his upper extremity and will continue to apply ice at night. We will see the patient back in four weeks’ period of time.

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