Suspected subacromial bursitis

The patient presents today for routine follow-up. He will continue with physical therapy later today. He underwent a left subacromial steroid injection under fluoroscopic guidance by Dr. on April 3, 2013. He states that this continues to help significantly. He does state continued “clicking” throughout the shoulder.

Patient’s issue began due to motor vehicle accident on January 3, 2012. He was a driver of a Mazda and had a co-worker passenger in the front seat. He states he is right-handed and that his work as a carpenter has not been affected too badly at this point as the injury is in the left shoulder. He states he had his hand on the steering wheel as he braced for impact and was hit from behind and then hit the car in front of him. He has no new complaints and no worsening of his condition since his injection.

IMPRESSION:
1. Suspected subacromial bursitis.
2. Status post MRI of the left shoulder; I do not have the results readily available.
3. MRI of the cervical spine showing a C6-C7 disc herniation.
4. The patient has not had an orthopedic consultation.

PLAN:
I recommended him to continue with his physical therapy at this point. I have also recommended that he be evaluated by an orthopedic surgeon. He has also had EMG in the past as well. He will follow up in the next four to eight weeks for re-evaluation and was advised to continue with his physical rehabilitation regimen.

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