CC: R L Shoulder Elbow F/U TSA Hemi R&R RCR Bankart Delta TEA

Name:From:

Age: ♂ ♀

Dominant Hand: R LOccupation:

Hx:

Pain: Onset:Hx Trauma:

Strength:

ROM/Stiffness:

Instability:

Crepitus/Smoothness:

SST NOs R: 1 2 3 4 5 6 7 8 9 10 11 12 L: 1 2 3 4 5 6 7 8 9 10 11 12

SET NOs R: 1 2 3 4 5 6 7 8 9 10 11 12 L: 1 2 3 4 5 6 7 8 9 10 11 12

Medical Issues:See New Patient Information Form See Attached List
Ø CV
Ø DM
Ø Resp / Surgeries:See New Patient Information Form See Attached List
Medications:See New Patient Information Form See Attached List / Allergies:See New Patient Information Form
 NKDA  PCN  Sulfa

ROS:See New Patient Information Form

Const / Eyes / ENT / Allergic/Immuno
Resp / GI / GU / Hemato/Lymph
CV / Neuro / Psych / Skin/ Integ
Endo / MS / Rest Neg
SHx: Smoker: Nonsmoker _____PPD_____PPW
ETOH: NondrinkerOccasionalRare / FHx:See New Patient Information Form

PE: Well developed, well nourished ♂ ♀ in NAD PSYCH: Judgment, insight, memory, mood and affect within normal limits. Tobacco Smell

R ROM / R Str (-/5) / L ROM / L Str (-/5) / Wound C/D/I Ø erythema or signs of infection
Ø obvious deformity noted on visual inspection

FE / S. Spinatus / FE / S. Spinatus
ER / ER / ER / ER
IR / IR / IR / IR
IRA / Delt / IRA / Delt
ERA /  Bicep Saw Nml / ERA /  Bicep Saw Nml
CBA / SILT M/R/U / CBA / SILT M/R/U
 Unstable /  EPL/FPL/IO Intact /  Unstable /  EPL/FPL/IO Intact
 Crepitus / IR Lift off Nml /  Crepitus / IR Lift off Nml

Imaging:

XRay: R L Ø Fx Ø dislocation Prosthesis in good anatomical alignment
Glenohumeral joint space is: preserved decreased
Arthritis Ant Pos Wear pattern High riding Humeral Head / R L MRI
Full Part Ø RCT

Assessment: DJD RCT RC Arthropathy Shoulder Instability Normal Post Surgical Course

Plan: Discussed surgical and non-surgical management options to include risks and possible benefits of each.Intro to surg schedulerOrder MRI

Smokingtalk

F/U: 2 3 4 6 wks months If Ø improvement After MRI
Seen & Exam with Consulted with Caroline Chebli Frederick A. Matsen / Visit Greater than 50% Counseling
Est / 5 -211 / 10 -212 / 15 - 213 / 25 - 214 / 40 - 215
New / 10 - 201 / 20 - 202 / 30 - 203 / 45 - 204 / 60 - 205