ER Visit- Concise FRASER HEALTH AUTHORITY

Subjective:
CHIEF COMPLAINT:
Persistent right shoulder pain for 2.5 weeks, worsening at night and interfering with sleep and daily activities.

HISTORY OF PRESENT ILLNESS:
- Pt is a mechanic presenting with c/o persistent R shoulder pain for 2.5 weeks, worsening at night, interfering with sleep and daily activities.
- Pain described as constant, exacerbated by lifting the arm, with shooting pain radiating to the neck.
- No hx of direct trauma or specific injury to the shoulder.
- Similar episodes in the past, resolving within days without intervention; this episode is prolonged.
- No prior imaging or investigations for the shoulder.
- PMHx includes HTN managed with amlodipine 5 mg qd, and hypercholesterolemia managed with lifestyle modifications.
- Allergic to penicillin.
- No hx of surgeries related to the shoulder, no hx of sport injuries.
- Social hx: occasional alcohol use, no smoking.

PAST MEDICAL HISTORY:
1. Hypertension managed with amlodipine 5 mg qd.
2. Hypercholesterolemia managed with lifestyle modifications.
3. Allergic to penicillin.
4. No recent surgeries; last surgery was hernia repair at age 12.
5. No smoking history.
6. Occasional alcohol consumption.
7. No prior imaging or investigations for the shoulder.
8. No history of sport injuries or direct trauma to the shoulder.

MEDICATION (INCLUDING ALLERGIES):
1. Amlodipine 5 mg qd.
2. Omega-3 supplements.
3. Allergic to penicillin.

Objective:
PHYSICAL EXAMINATIONS:
GENERAL:
- Alert, cooperative, and in no acute distress.
- Difficulty lifting right arm due to pain.

HEART:
- Regular rate and rhythm.
- No murmurs, rubs, or gallops.

MUSCULOSKELETAL:
- Right shoulder: Full range of motion with pain.
- Tenderness localized to the AC joint.
- No tenderness in the humeral joint.
- Strength preserved in the right shoulder.
- Negative for rotator cuff injury.

NEUROLOGICAL:
- No focal neurological deficits noted.

INVESTIGATIONS (INCLUDING ORDERS/RESULTS):
No imaging or prior investigations performed for the shoulder. No X-rays or other diagnostic tests ordered during this visit.

ER TREATMENT & REASSESSMENT:
- Discussed persistent right shoulder pain localized to the AC joint, with no evidence of rotator cuff injury or humeral joint involvement.
- Recommended naproxen 500 mg BID for one week with meals to manage inflammation and pain.
- Advised icing the shoulder to reduce inflammation.
- Educated on potential GI side effects of NSAIDs, including gastritis and black stools, and instructed to stop medication if symptoms occur.
- Encouraged activity as tolerated without excessive force.
- Follow-up with family physician in 1-2 weeks or return to ER if symptoms worsen.

Assessment:
PRIMARY ER DIAGNOSIS:
Right AC joint inflammation.

Plan:
DISPOSITION AND MANAGEMENT PLAN:
- Discharged home with prescription for naproxen 500 mg BID for one week.
- FU with family physician in 1-2 weeks.
- Return to ER if symptoms worsen or new symptoms develop.

MEDICATIONS & MANAGEMENT:
1. Naproxen 500 mg BID PO with meals for 1 week.