Right Shoulder Pain Case Studies
CC
Andrew is a 31-year-old male here today complaining of right shoulder pain.
HPI
The patient tells me his right shoulder has been bothering him for several years. He had multiple traumas when he was younger playing lacrosse, was having issues with recurrent dislocations of his right shoulder and ultimately underwent flap surgery with David Thut, MD in 2010. He says since that time, his shoulder has never actually been back to normal. He has had increasing pain in the right shoulder. He started noticing it coming on worse in the spring when he started playing golf and he tries to play golf at least once or sometimes more a week. He would particularly notice [_:50___] on Monday morning, if he had played golf on the Saturday prior. He would be sitting
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A/P
Andrew Strosahl is a 31-year-old male here today for several issues.
Right shoulder pain. He reports that this pain has worsened with his activity recently. He is going to hold off on the yoga poses and the golf for now and try to give his shoulder a rest. I wrote him for naproxen 500 mg one p.o. twice daily #30 with no refills to use a scheduled basis for the next five to seven days and then p.r.n. from there and he plans on following up with Dr. Thut. Consideration for further investigation can be done then. We will assist him in helping to get this scheduled. Should he have any new injury or concerns in the meantime, he will update me.
His right ear pain. I did reassure him that his ear was normal today on exam. It is feeling better now and he would just like to monitor it. Certainly if the pain comes back or he has new issues, he can let me know. I will be happy to look again.
A referral was made for dermatology in Dover. That will be scheduled at his earliest convenience.
He will follow up for routine care sooner follow up as necessary. He does voice understanding of these recommendations. All questions
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