Assessment
1. Pain in Achilles tendon (M76.60)
Patient presents for posterior ankle pain that started yesterday after she was getting out
of the car and she felt a pop. Surprisingly she does not have bruising or swelling of the
ankle. No real tenderness to the area of concern. She has negative Thompson test.
Given that she felt a pop I do think we should still assess Achilles tendon. We did speak
with Envision Sally Jobe and they were able to get her in as a walk-in so we should have
this back today. Will obtain musculoskeletal ultrasound. Recommend RICE.
2. Shoulder impingement, left (M25.812)
Physical exam consistent with shoulder impingement. Recommend physical therapy
which she is agreeable for. Will send referral to epic PT. If no
improvement in 4 to 6 weeks recommend MRI. Follow-up with any worsening and we will
obtain MRI.


Plan
 US Ankle MSK Non Vascular RIGHT - 76881ARE Envision/Health Image; Status:Active;
Requested for:01Feb2024;

Chief Complaint

44 y/o female here for a right ankle pop and swelling from 1/31
Pain with weight bearing.
Left rotator cuff pain

History of Present Illness

Camille is here today for a routine visit. She reports yesterday she was getting out of her car and felt a pop in the back of her right foot near her Achilles. She reports since that time she has had pain which is worse with ambulation. She is able to bear weight however walks with a limp. She has also had some decreased range of motion of the right ankle. No swelling or bruising. She has been icing the foot which has been helping. She reports it does feel better today. She denies any recent change in physical activity. No recent injuries to the right ankle.

Left shoulder pain-she also wanted discuss pain she has been having in her left shoulder for the last year and a half. Pain is located on the lateral aspect of the left shoulder. She reports pain is intermittent. Exacerbated by certain movements and does notice it more at night. She reports the most recent time she had the worsening pain was roughly 3 months ago after she was lifting. She reports pain is worse with abduction. She is right-handed. Denies any injury to the left shoulder.

Review of Systems


Other Symptoms: see hpi.
The review of systems was otherwise negative.

Vitals
Vital Signs
Recorded: 01Feb2024 07:10AM
Systolic: 118, LUE, Sitting
Diastolic: 20, LUE, Sitting
Temperature: 98 F
Respiration: 16
Heart Rate: 85
Height: 5 ft 6 in
Weight: 181 lb
BMI Calculated: 29.21 kg/m2
BSA Calculated: 1.92
O2 Saturation: 95 %, Room Air
FiO2 Flow Rate: 0 L/min, Room Air


Physical Exam

GENERAL: Well appearing female, well-nourished and in no acute distress.

PSYCHIATRIC: Normal judgment and insight, A&Ox3. Mood and affect normal

UE Left Shoulder: Appearance: no ecchymosis, no erythema and no swelling. Tenderness: deltoid. Special Tests: positive Painful Arc and positive Empty Can test.
LE Right Ankle: Appearance: no Achilles defect, no Achilles thickening, no deformity, no ecchymosis, no erythema, no swelling, no lateral swelling and no medial swelling. Tenderness: not the Achilles tendon insertion, not the lateral malleolus and not the medial malleolus. Dorsiflexion: painful restricted AROM. Plantar flexion: painless normal AROM. Inversion: painful restricted AROM. Eversion: normal AROM. Special Tests: negative Thompson Test.

Current Meds:Medication reconciliation occurred to include current, discontinued, and post-hospital discharge medications. Note: New medications or modifications to current medications found in the plan section of the note. For any dosing changes and new medications started, the risks and benefits were discussed with the patient.
Medication Name
Instruction
Omeprazole 40 MG Oral Capsule Delayed Release
TAKE 1 CAPSULE Daily

Active Problems
1. Abnormal urinalysis (R82.90)
2. Acute diarrhea (R19.7)
3. Atypical chest pain (R07.89)
4. Dysphagia (R13.10)
5. Epigastric pain (R10.13)
6. GERD (gastroesophageal reflux disease) (K21.9)
7. History of gastric ulcer (Z87.11)
8. Hot flashes (R23.2)
9. Microscopic hematuria (R31.29)


Past Medical History
1. History of Anxiety and depression