History and Physical – Rotation 2

Matt Lemieszewski
Rotation 2 – Ambulatory Care

Identifying Data

February 10th, 2022 – 15:45
JF, 23M, Black, Queens,NY
Informant: Patient, reliable
Referral Source: self

Chief Complaint: left shoulder pain x 45 minutes

History of Present Illness:

JF is a 23-year-old male with no significant past medical history who presents to StatCare-Astoria with his grandmother after sustaining a left shoulder injury while playing basketball this afternoon. The patient states that while playing basketball, he was directly on his left shoulder by another player’s hip, causing him to fall to the ground. No head strike. No LOC. Upon standing, patient was unable to dribble the basketball with his left hand and currently cannot make any movements with his left arm due to the pain. He describes the pain as a severe ache, rated 8 out of 10 in severity. Pain is mildly improved when stabilized by the patient’s right arm. He has not taken anything for the pain since the incident. Patient denies pain to the left elbow, forearm, wrist, or hand. No radiation to the neck. The patient has no other current complains.

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history


  • No current medications



Family History:

  • Father: Alive, unknown medical history
  • Mother: Alive, unknown medical history

Social History:

  • Diet: Does not follow any specific dietary regimen
  • Home: Lives at home with his parents and maternal grandmother
  • Smoking: Denies current or past use of cigarettes, e-cigarettes, or other tobacco products
  • Alcohol: Socially drinks when out with friends
  • Drugs:  Denies use of any illicit drugs.
  • Sleep: Sleeps 7-8 hours per night, using 2 pillows.
  • Travel: Denies any recent travel

Review of Systems:

General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Denies corrected vision. Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis. Last eye exam in September 2021.

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, allergies, or epistaxis

Mouth and throat: Denies sore throat. Denies bleeding gums, ulcerations. Does not wear dentures. Last dental exam in May 2021.

Neck: Denies localized swelling, lumps, stiffness, or decreased range of motion.

Pulmonary: Denies shortness of breath, wheezing, or productive cough. Denies hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

Cardiovascular: Denies chest pain, palpitations, edema, irregular rhythms.

Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain.

Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria. Denies any history of STDs.

Nervous: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.

Musculoskeletal: Positive joint pain in left shoulder along with swelling, weakness, and changes in range of motion.

Peripheral Vascular: Denies peripheral edema. Denies intermittent claudication.

Hematologic: Denies history of DVT/PE or previous blood transfusions.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.

Physical Exam:

General: 23M, A&O x3, sitting on exam table, holding left arm in place, grimacing due to pain. No acute distress. He is well groomed and well-developed for age. He does not appear ill.


  • BP(Seated): R – 115/68 (unable to perform on left)
  • P: 74, regular
  • R: 18breaths/min, unlabored
  • T: 97.3F (36.3.C), oral
  • O2 Sat: 97% on room air
  • Height: 66 inches – Weight: 181lbs – BMI: 29.2 – Overweight  

Skin: Warm and moist with good turgor throughout. Nonicteric. No lower extremity erythema and warmth. Nontender on palpation. No cyanosis or jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic, nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

  • Visual uncorrected – 20/30 OS, 20/30 OD, 20/25 OU
  • Visual fields full OU.  PERRLA, EOMs intact with no nystagmus 
  • Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU. 


  • Lips: Pink and moist with no lesions
  • Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
  • Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact. 
  • Teeth: Good dentition with no obvious dental caries noted.
  • Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
  • Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: Wheezing present bilaterally. No rhonchi or rales. Chest expansion and diaphragmatic excursion symmetrical.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.

Abdomen: Abdomen is symmetric with striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to light palpation, tender on deep palpation in epigastric and suprapubic regions. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated


  • Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.

  • CN II-XII grossly intact.

  • Motor/Cerebellar: Full active/passive ROM of 3 of 4 extremities without rigidity or spasticity. Severely limited ROM detected in LUE, outlined in MSK. No atrophy, tics, tremors, or fasciculation.

  • Reflexes:
  • Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, no edema present. Pulses are 2+ bilaterally in upper and lower extremities.

Musculoskeletal: No edema or erythema present on bilateral lower extremities without soft tissue swelling, or tenderness. FROM of bilateral lower extremities and right upper extremity. Bilateral shoulder height symmetrical. No obvious deformities.

Left upper extremity: No redness, bruises, or deformities. Shoulder flexion limited to 90 degrees secondary to pain. Unable to extend, externally rotate, or abduct. + Pain on internal rotation. + tenderness to palpation of AC joint and axilla. No tenderness to palpation of clavicle, humerus, or elbow. (+) Empty can test. (+) Neer’s test. (+) Crossover (scarf) test. (-) Apley test.


JF is a 23-year-old male with no past medical history who presents to our clinic for left shoulder pain.

Differential Diagnosis:

  1. Labrum/Rotator cuff tear
  2. Shoulder strain/sprain


#Left shoulder injury, R/O tear vs sprain

  • Left upper extremity x-ray and MRI referral
  • Patient educated and advised regarding RICE therapy
    • Avoid strenuous activity, sports, or heavy lifting
    • Active stretching as tolerated
  • Return to clinic or proceed to ED if signs and symptoms of neurovascular compromise develop

#Ongoing left shoulder pain

  • Start Naproxen 500mg PO q12h PRN x7days
  • Provide sling and swathe shoulder immobilization in a position of comfort
    • Ensure circulation and sensation in the distal extremity