Left Shoulder Injury Case Study
Reason for Visit: Left Shoulder Visit
Vital Signs - B/P: 148/90 Temp: Pulse: 54 Resp: 16 O2 Sat 99%
S: TM is here complaining of his left shoulder. TM been having shoulder pain for some time but for the past several days the pain has gotten greater and it seems like his shoulder is about to come out of his shoulder. He reports his pain is about 5 to 6 out of 10 in daily bases. TM denies any numbness or tingling sensation in his arms or hands, but his grip strength in his left hands are not strong as it has been. TM denies any acute injury to left shoulder, denies any previous injury to left shoulder. After ice X 20 minutes, the TM reports his pain at 4/10.
O: On inspection, no edema or discoloration noted to his left shoulder. TM reports
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