1/5/22, 7:40 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Four DOB: 11/20/1998

1/20/1998 PRN: FP70755

PATIENT FACILITY ENCOUNTER

Princess Arianne Macaranas Four Hello Rache Practice NOTE TYPE SOAP Note
DOB 11/20/1998 T (520) 468-5817 SEEN BY Princess Arianne
AGE 23 yrs 4990 E Mediterranean Drive, Macaranas
SEX Unspecified Suite D, DATE 01/05/2022
PRN FP70755 Sierra Vista, AZ 85635 AGE AT DOS 23 yrs
Not signed

Chief complaint
Shoulder Injury

Patient identifying details and demographics

FIRST NAME Princess Arianne SEX Unknown RACE -
Macaranas DATE OF BIRTH 11/20/1998 ETHNICITY -
MIDDLE NAME - DATE OF DEATH - PREF. LANGUAGE -
LAST NAME Four PRN FP70755 STATUS Active patient
SSN -
CONTACT INFORMATION
ADDRESS LINE 1 - CONTACT BY -
ADDRESS LINE 2 - EMAIL -
CITY - HOME PHONE -
STATE - MOBILE PHONE (520) 345-6789
ZIP CODE - OFFICE PHONE -
OFFICE EXTENSION -
FAMILY INFORMATION
NEXT OF KIN - PATIENT'S MOTHER'S MAIDEN -
RELATION TO PATIENT - NAME
PHONE -
ADDRESS -

Vitals for this encounter

No vitals recorded

Subjective
SUBJECTIVE
HPI-ROS:

The patient is here for his shoulder Injury. He had his right shoulder injured yesterday and has not gone into any shoulder injury
prior to the visit. He feels some snap every time he lift something and he feels pain afterwards,

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
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1/5/22, 7:40 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Four DOB: 11/20/1998 PRN: FP70755

Musculoskeletal: Remarkable for pain in the right shoulder.

Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

Objective
OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal. CN 2-12 intact. No cognitive
dysfunction. No sensory or motor deficits. Gait normal.
Assessment
1. The doctor advised the patient to get an MRI for his shoulder.
2. The patient was advised to take a medication 75 mg medication refill will be sent to Target.
3. Doctor advised the patient to rest his shoulder and avoid lifting heavy objects he will use sling for his shoulder because it will just
freezes his shoulder after a week of using instead the doctor told him to tilt his shoulder up and down and rotate in circles do it
once a day.
4. Patient advised to go back in the clinic after a week to see the MRI result.
Plan

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