RK is a 26 year old married Caucasian female working as a waitress while attending nursing school.
Source: RK, reliable.
Chief Complaint: “My right shoulder hurts”
HPI: Noticed shoulder pain while working 3 days ago, lifts heavy trays, pain hasn’t resolved with rest. Doesn’t recall a specific injury/incident. Describes anterolateral shoulder pain and burning sensation that worsens when lifting arm over head or lifting trays at work.
Past Health: Depression
Childhood Illnesses: Pt has been generally healthy. Had Chickenpox as a child. Received all recommended childhood vaccines. Denies having Measles, Mumps, Rubella, Pertussis, Croup, or Rheumatic Fever.
Accidents: States fractured both wrists as a child, one Fx r/t Trampoline,
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No change in appetite, weight, hair or skin.
Functional Assessment
Self Concept: Graduated from community college and is presently in nursing school. Works part-time on weekends as a waitress. Is married and has one child at home. Financial status is stable and adequate to meet needs. Believes in God, attends church occasionally. Sees self as independent, dependable & honest.
Activity-Exercise: Activities change daily due to college schedule. Jogs twice weekly. Works weekends. Independent with all ADL’s. No assistive devices needed. Has no specific hobby but enjoys outings and activities with her daughter.
Sleep-Rest: Sleeps well, 8-9 hours per night, no sleep aids.
Nutrition: 24 recall: Breakfast- Cereal with banana & milk, & a cup of coffee. Lunch-Chicken sandwich, waffle fries, Dr. Pepper. Dinner-Spaghetti with meatballs, garlic toast, salad & iced tea. Snacks- fruit, granola bars. Drinks water between meals ~ 1 liter/day. No food intolerances.
Alcohol: Has a rare to occasional glass of wine, no cigarette use. CAGE ‘no’ to all
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No lumps, lesions or tenderness. No facial weakness or involuntary movements.
Eyes: Visual acuity 20/20 (corrected with contact lenses) in each eye per Snellen chart. No ptosis, crusting or discharge. Lashes evenly distributed. No eye protrusion, normal alignment. Sclera white, conjunctiva clear, pink, cornea clear. EOM intact, no nystagmus. PERRLA. CNs III, IV, VI intact.
Ears: Auricles: No discharge, masses, lesions, or discharge. Symmetrical, mobile, no tenderness to palpation. Canals: Clear no cerumen noted. Whispered voice heard bilaterally.
Nose: Symmetric, no deformity or inflammation. Bil. nares patent, mucosa pink, no discharge. No septal deviation. Turbinates w/o swelling, exudate or polyps. No sinus painto palpation.
Mouth: Lips pink, symmetric. Mucosa pink, moist, without lesions. No evidence of periodontal disease, gums pink, not receding, no missing teeth. Tongue pink & moist, midline, symmetric. Pharynx pink, no exudate noted. Tonsils not observed. Uvula midline. No mouth odor noted. + gag reflex.
Neck: Full ROM. Symmetric. Trachea midline. Thyroid gland not enlarged, non-tender. No lymphadenopathy, masses or discomfort. No JVD. No carotid bruits, pulse =