PAST MEDICAL HISTORY:  Significant for back injury. He had anterior fusion of L3-L3 in the past. He has had multiple episodes, about one a month, since the surgery of exacerbation of his chronic back pain. This typical pain pattern with numbness and radiation down the leg, he states, is nothing unusual for the last multiple episodes. He has had no bladder or bowel dysfunction.

SOCIAL HISTORY:  He is a smoker.

OBJECTIVE:  The patient is alert, in no acute distress, obviously uncomfortable however. C-spine is negative. He is tender over the mid back, L2 through L4 with paravertebral muscle spasm that is palpable, also quite tender. Decreased range of motion. The patient is alert and orientated x3. No motor deficits. Strength 5/5. He does have diminished left patellar reflex. Decreased sensory on the left great and little toe, medial aspect of the foot and lateral aspect on the plantar surface of the foot. Sensory is intact.

INTERVENTION:  At this time, we suggested doing the MRI that Dr. John Doe had suggested. The patient instead wishes to follow up with another facility and get the MRI done there, which we agreed with, as long as he does it in a rapid fashion.

ASSESSMENT:
1.  Acute myofascial strain.
2.  Acute exacerbation of chronic low back pain.

PLAN:  Percocet 5 mg 1-2 q.4-6 hours as needed for pain, Soma one three times a day, Indocin SR 75 mg b.i.d. with food. Follow up with the specialist who did his back surgery for reevaluation of his increasing back pain over the last several years. Any acute problems, recheck sooner. Any problems with bladder or bowel, recheck immediately.

SUBJECTIVE:  This (XX)-year-old male came in with an injury to his right shoulder yesterday afternoon at work. He was resting and he tweaked the shoulder. He is not sure of the mechanism. He was sore all of last night. He pulled on a door handle, pushing its handle down and pulling it straight back and had quite a bit of pain when he did this. He came in with increased pain. He is right handed. Prior injury two years ago to the shoulder. He had injection by Dr. John Doe after an MRI. MRI results were reviewed and showed a biceps tendinitis.

OBJECTIVE:  The patient is alert and in no acute distress. The patient is tender over the soft tissue of the shoulder. No swelling or ecchymosis. No deformity. The patient is point tender over the biceps tendon. He is also tender over the lateral deltoid and over the supraspinatus tendon area. Both are equally tender. Pain with biceps range of motion. Also, has painful range of motion in abduction and internal rotation, both active and passive. He does have grip strength. No evidence of rotator cuff tears at this time. Distal neurosensory examination is intact. Motor is intact. Strength is symmetrical. No vascular compromise. C-spine is negative. Trapezius muscles are negative.

Right shoulder x-ray reviewed by Dr. Jane Doe is negative.

INTERVENTION:  At this time, we discussed injection versus anti-inflammatory medications. We are going to start with conservative therapy.

ASSESSMENT:
1.  Biceps tendinitis, right shoulder.
2.  Supraspinatus tendinitis, right shoulder.

PLAN:  The patient did not wish any narcotic pain medication. Ibuprofen 800 mg q.6 hours. Ice to the shoulder. Recheck in 5-7 days, sooner if worse. If not improved, consider injections.

SUBJECTIVE FINDINGS: At the time of the initial evaluation, the patient complained of a dull ache in the upper back at the level of 1 and 2 on a scale of 10. The patient states that the pain increases, especially, at the end of the day to a level 5-6 on a scale of 10. The patient is using heat at home. He also uses a hot tub with good pain relief.

OBJECTIVE FINDINGS: Cervical spine range of motion is within functional limit with pain to upper thoracic back with flexion and extension. Thoracic spine range of motion is within functional limits. Cervical spine strength is 5/5. Right lateral upper extremity range of motion is within functional limit and strength is 5/5. Palpation is positive over paraspinal muscles at the level of C7 through T3 with the right side being more than the left. Sensation is within normal limits. Biceps reflex test is 1+ bilaterally. Triceps reflex test, we were unable to elicit.

TREATMENT PLAN: We would like to see the patient for modalities, including moist hot packs, ultrasound, deep tissue massage, and for therapeutic exercises.

TREATMENT GOALS: Goals of physical therapy are:
1. Decrease pain to 0.
2. Improve function to normal.

SUBJECTIVE FINDINGS: This patient is a (XX)-year-old Hispanic female with pain in her lumbosacral spine on the right at the level of approximately L3-L4. She also has pain in her right shoulder. She states that the pain increases with activity and diminishes to zero, normally, with rest. The pain is intermittent and increases with certain motions and usually it takes a while to resolve. She is using Bextra p.r.n. and ibuprofen.

HISTORY: This patient had an insidious onset of pain approximately six months ago associated with stomach pain. She also began having pain in her right shoulder in May beginning with some swelling in her shoulder. The swelling subsided but some pain remains. The patient sought intervention from Dr. John Doe and was referred here.

OBJECTIVE FINDINGS: Observation: This patient appears a normally developed Hispanic female of stated age. She gaits and moves normally without splinting or with some posturing of her right shoulder. Palpation positive over the anterior surface of the shoulder, negative in the low back. Range of motion within normal limits with pain with right side bending. Resisted motion positive in right side bending. Shoulder range of motion limited in internal rotation to 25 degrees, all other motions within normal limits. Resisted motion positive in full flexion, abduction, and external rotation in a dependent position. Radiculopathy positive with pain radiating from the shoulder to just above the elbow.

TREATMENT PLAN: We would like to see the patient three times per week for modalities to decrease pain and exercise to increase strength and function.

TREATMENT GOALS: Goals and purpose of physical therapy intervention is to:
1. Decrease pain to zero.
2. Increase strength and function to normal.
3. Increase range of motion to normal.