[doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since .
[doctor] hi mr . james , i'm doctor isabella . how are you doing ?
[patient] i'm okay . thank you .
[doctor] that's good . that's good . tell me what's brings you in today .
[patient] sure . so i've been having constant pain in my left shoulder and left elbow for a while , about five months or so . hurts all the time . pretty bad at times .
[doctor] mm . that does not sound like fun . it sounds like you injured it going up the stairs ?
[patient] yes , that's correct . it was icy , and i have to walk up a flight of stairs to my house . i stepped and my feet just went out . fell on my left side . seems like my shoulder and wrist took the brunt . it's been hurting since .
[doctor] yeah , that does seem like a likely cause of your symptoms . anything seem to make the pain worse ?
[patient] well , i've always hit the gym and lifted weights . i've been trying to keep with my routine of two days a week , but it's been hard . the pain is worse when i lift , and i have n't been able to lift more than 15 or 20 pounds which is very frustrating .
[doctor] mm-hmm . i can imagine it is when you're so accustomed to your routine .
[patient] exactly . i really enjoy my exercise , but over the past one to two weeks , i've stopped hitting the gym because the pain just was n't worth it honestly . i do keep up with my walking , though . my wife and i walk about 30 minutes almost every day . we have done this since i retired from my office job last year .
[doctor] i do not blame you , mr . james . does anything seem to help the pain that you've tried ?
[patient] not too much . i have iced a bit , but i have not taken anything for the pain . stopping exercise and some ice has helped a bit , but it still hurts enough for me to come to see you .
[doctor] yeah , okay . how about any numbness or tingling ? have you felt that at any point ?
[patient] no , doc . just pain . no tingling or numbless , numbness , thankfully .
[doctor] understood . understood . all right . well , let's go ahead and take a look and see what's going on .
[patient] sounds good . thank you .
[doctor] okay . use my general physical exam template . mr . james , i'm going to gently press around your shoulder and elbow here to see where your pain might be stemming from . just let me know when it hurts .
[patient] okay . it hurts when you press there on my elbow and here on my shoulder .
[doctor] okay . left shoulder and elbow , tender sa space , no warmth , erythema or deformity . positive hawkins-kennedy and neer's test . normal proximal and distar , distal upper extremity strength . intact median radial ulnar sensation and abduction to 90 degrees . normal empty tan , can test . okay , mr . james , w-what i think you are dealing with is impingement syndrome of your left shoulder . i do n't think there's an additional injury or issue with your wrist , but because everything is connected , you're experiencing pain in your wrist because of your shoulder . we do see this type of issue when someone has a fall , so it's good you came to see us , you came in to see us so we could help .
[patient] so what are the possible treatments ?
[doctor] well , we have a few options you can try . first option would be to start with physical therapy . i would recommend two sessions per week as well as any other exercises they give you to do at home . we can start there and if that does n't improve your pain , then we could try a cortisone injection .
[patient] i like the idea of starting with the physical therapy and have a next step if it does n't help . i am not opposed to a shot but would like to try the therapy first .
[doctor] all right . great . i'll get a referral order , and they will call you within the next day or two to get you scheduled .
[patient] okay .
[doctor] mm-hmm . also , please continue to ice , especially your shoulder , and rest as much as you can .
[patient] okay . i will .
[doctor] give us a call or email us if you have symptoms worsen , if your symptoms worsen or do not improve with the therapy .
[patient] will do . thank you . i appreciate your help .
[doctor] you're welcome . have a great day .
[patient] you too .
[doctor] all right . assessment is impingement syndrome of left shoulder . plan discussed with patient . referral is requested for dr. martha rivera to be in physical therapy two days per week .

Medical orders:
description: cortisone injection
order_type: medication
reason: impingement syndrome of left shoulder