274230067 EH
11456974
175762
02/04/1990 12:00:00 AM
Discharge Summary
Signed
DIS
Admission Date :
02/04/1990
Report Status :
Signed
Discharge Date :
02/13/1990
PRINCIPLE DIAGNOSIS :
LEFT ROTATOR CUFF TEAR .
HISTORY OF PRESENT ILLNESS :
The patient is a 52-year-old right handed male with a many year history of bilateral shoulder pain , right greater than left .
He has steroid injections in the right and in the left four times .
Arthrogram in the distant past showed a right rotator cuff tear and he now has increased pain in his left shoulder .
MRI by report showed bilateral rotator cuff repairs and he was admitted for repair of the left rotator cuff .
PAST MEDICAL HISTORY :
Back pain .
PAST SURGICAL HISTORY :
Ankle surgery times two on the right .
Pilonidal cyst removal .
MEDICATIONS :
On admission included Naprosyn .
ALLERGIES :
NO KNOWN DRUG ALLERGIES .
HABITS :
The patient smokes two packs per day and has an approximately a 75-pack-year history of smoking .
He has a history of drinking which he discontinued in May .
PHYSICAL EXAMINATION :
On admission revealed a white male with no palpable adenopathy .
HEENT exam was within normal limits .
Lungs revealed occasional wheezing bilaterally at both bases .
Heart was regular with a I / VI systolic ejection murmur without jugular venous distention .
Pulses were 2+ bilaterally .
Abdomen was obese with positive bowel sounds , nontender , nondistended .
Examination of his shoulder revealed the patient to be able to flex his right arm to 170 degrees , internally rotate to 10 degrees and externally rotate to 40 degrees with positive joint tenderness .
All range of motion with his right shoulder was painful .
The left shoulder was identical in range of motion and was also painful .
HOSPITAL COURSE :
The patient was admitted with the assessment of left rotator cuff repair and he was taken to the Operating Room on the day of admission where he underwent left rotator cuff repair under general endotracheal tube anesthesia .
There were no intraoperative complications .
His postoperative course was generally unremarkable except for a prolonged course of advancement with range of motion of his left shoulder .
Occupational therapy became involved initially and he remained on patient controlled analgesia secondary to problems with left shoulder pain .
He was kept in the hospital for an extended period to improve his postoperative range of motion .
However , he was eventually able to achieve forward flexion of 135 degrees and external rotation of 30 degrees by postoperative day number eight .
His wound remained clean and dry and showed no signs of infection and healed well .
However , his course was otherwise complicated by discovery of persistently elevated blood sugars and Endocrinology was consulted to rule out possible newly diagnosed diabetes .
His hemoglobin A1C levels actually came back within normal limits , however , the wide excursions of his sugars were consistent with possible diabetes .
He was placed on a diabetic diet and his sugars did show some improvement .
It was not necessary to start him on oral hypoglycemics or insulin .
He also complained of occasional spells and jitteriness and some orthostatic dizziness and thus Neurology was consulted and EMG 's were performed which were normal .
His neurologist was contacted , Dr. Cap , and the exact of his problems was not demonstrated during this hospitalization , however , they felt that this could possibly be an autonomic type neuropathy maybe secondary to some underlying diabetic process .
Further work-up of his neurologic conditions were planned as an outpatient .
Thus , he was discharged on postoperative day number eight in good condition with a well healed left shoulder wound and doing well with occupational therapy with plans for him to follow-up with Dr. Necessary .
DISPOSITION :
MEDICATIONS :
On discharge included Valium , 2 mg po t.i.d.; Naprosyn , 500 mg po b.i.d. ________________________________ ZV061/6138 TICENA NECESSARY , M.D. WO00
D :
03/12/90
Batch :
2280
Report :
V1412C43
T :
03/14/89
Dictated By :
VITA THOSTERWEN LINKEKOTEMONES , M.D.