**Reason For Visit:**
Right shoulder pain and limited range of motion.
**Date of onset or injury or list the duration of symptoms. List the duration of symptoms if no specific date is available. Otherwise estimate the duration using a term like "acute" or "chronic."**
Symptoms started approximately 6 weeks ago.
**Subjective:**
Mr. John Smith, a 55-year-old right-hand dominant male, presents with right shoulder pain. He works as a carpenter and enjoys playing golf on weekends. He denies any other associated injuries.
Mr. Smith reports the onset of right shoulder pain approximately six weeks ago, following a weekend of heavy lifting. The pain is described as a dull ache, exacerbated by overhead activities and at night. He denies any previous injuries to the shoulder. He has tried over-the-counter pain relievers with minimal relief. He reports that the pain is affecting his ability to work and play golf.
Mr. Smith is a carpenter and plays golf on weekends. He denies any other physical activities.
Mr. Smith denies smoking, drinks alcohol occasionally, and denies any illicit drug use.
**Past Medical History:**
Mr. Smith has a history of hypertension, well-controlled with medication. He had a left knee arthroscopy 5 years ago. He denies any other musculoskeletal disorders.
Mr. Smith is currently taking lisinopril for hypertension. He denies any other medications.
Mr. Smith denies any known drug allergies.
**Physical Exam:**
No obvious deformity or swelling was noted. There was no evidence of skin breakdown or infection.
Active range of motion: Flexion 120 degrees, abduction 90 degrees, external rotation 30 degrees, internal rotation to the level of T12. Passive range of motion was similar.
Tenderness to palpation over the supraspinatus tendon and the anterior aspect of the glenohumeral joint. No instability was noted.
Strength testing revealed 4/5 strength in abduction and external rotation. Sensation was intact to light touch in the deltoid region. Spurling's test was negative.
**Investigations/Other Studies Reviewed:**
Right shoulder X-rays were reviewed, showing mild acromioclavicular joint arthrosis.
**Assessment & Plan:**
1. Right shoulder impingement syndrome.
ICD-10 Code: M75.10, Unspecified rotator cuff syndrome.
ICD-10 Code: M75.12, Bicipital tendinitis.
Patient is progressing as expected.
Differential diagnosis includes rotator cuff tear, glenohumeral arthritis.
Plan for MRI of the right shoulder.
Referral to physiotherapy for conservative management.
Patient was informed of both operative and nonoperative treatment options. Nonoperative treatment includes physiotherapy, activity modification, and NSAIDs. Operative treatment includes arthroscopic subacromial decompression and/or rotator cuff repair.
Patient is interested in trying conservative management first.
**Follow-up:**
Follow-up in 4 weeks in person to assess response to physiotherapy and review MRI results. X-rays to be obtained at next visit.
**CPT Codes:**
99203: Office or other outpatient visit for the evaluation and management of a new patient.
73030: Radiologic examination, shoulder; 2 views.
