Patient Observation

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CC Joshua is a 30-year-old male here today with his wife and his two young children to follow up on recent labs as well as his last visit with me in June. HPI Please see the patient's first visit, which was June 17, 2015 for complete details. The patient tells me he did go to see Dr. Nordlinger regarding his right shoulder pain. Dr. Nordlinger did x-rays and recommended physical therapy. He went to a couple of physical therapy sessions, but said then he "got lazy", and he has not gone back since. He has not been doing home or formal physical therapy. He still has pain in his right shoulder. He describes it now as a dull pain, more than a sharp pain and only once in a while does he get that sharp pain, particularly at nighttime. He understands…show more content…
CBC without a differential normal, sed rate 12. He did repeat some labs for me at my request. These are dated September 17, 2015 showing liver function panel now AST 43, ALT 91. The rest of the panel is normal. CRP is now elevated at…show more content…
His right shoulder is bothering him, but even less bothersome than before. He is not having fevers, night sweats, or chills. There has been no weight loss without trying. He is eating and drinking normally. He has had no dizziness or lightheadedness. No URI, cold symptoms, or allergy symptoms. He is not having shortness of breath. No chest pain. There has been no belly pain or back pain. No other joint pain, swelling, or redness has been noted. No urinary frequency, urgency, or dysuria. Stools have been completely normal as well. He has absolutely no other symptoms that he has been able to identify. He rarely drinks alcohol, drinks perhaps a drink every other month or so. More recently, this past weekend, he went to a wedding and had six beers over the course of three days, but this is very unusual for him. He otherwise does not drink alcohol. He has never used drugs now or in the past. No exposure to hepatitis that he is aware of. He has been a lifetime nonsmoker. Medications Zyrtec 10 mg daily, Nexium 40 mg daily, ibuprofen as needed. Objective Vital Signs Temperature: 98.6. BP: 124/74. HR: 82. R: 14. W: 249. General A well-developed, well-nourished male, in no acute distress, seated comfortably in the exam room. He is alert and oriented. Very pleasant. Neck Supple. No masses or tenderness. No bruits or JVD. Heart Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,

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