Unknown #7

HISTORY:

A 78-year-old male presented to a Doctor of Chiropractic on 8-14-00 with pain in the left shoulder and neck stiffness. There is history of a rotator cuff tear approximately three years ago which occurred after a slip-and-fall accident and there has been left shoulder problems intermittently since that time. On the most current visits, there was increasing difficulty moving his neck as well as increased left shoulder pain extending along the left shoulder blade region. He was doing his exercises regularly which had been prescribed for his rotator cuff injury and had done nothing out of the ordinary to bring on the pain which is quite sharp with movement, occurs frequently, and is not changing. Patient was a smoker for years and has a history of diabetes mellitus.

CLINICAL AND ORTHOPEDIC FINDINGS:

Orthopedic evaluation revealed loss of abduction motion with loss of strength in both abduction and external rotation. There was focal pain at the rotator cuff insertion site on the greater tuberosity. Other orthopedic tests were essentially negative. Trigger points in the levator scapula and teres minor reproduced some of the shoulder pain. The patient was neurologically intact.

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9-11-00

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