DATE OF CONSULTATION: MM/DD/YYYY
CONSULTING PHYSICIAN: John Doe, MD
REQUESTING PHYSICIAN: Jane Doe, MD
ATTENDING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Left rotator cuff tear.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was admitted with complaints of chest pain and left side upper extremity numbness. He continues to have left upper extremity numbness that he notes wakes him up at night. He says he shifts positions when possible and does not feel that there has been any change with overall occurrence of numbness. He does not really complain of pain during the day.
He has a history of injury about a year ago when he fell on the left upper extremity. He says he had significant amount of weakness and inability to use the arm for about 3 months. He did not seek medical care at that time. He has pre-existing history apparently of hypertrophic cardiomyopathy. He has already been evaluated by cardiology. He has had an MRI of both his upper extremities as well as cervical spine. Apparently, his MRI of cervical spine showed rotator cuff tearing. He complains of some pain in the left upper extremity. He says he does feel weaker in this area. He admits that he had previously been noncompliant with his cardiac medications but says he is doing better at this point. He is right hand dominant.
PHYSICAL EXAMINATION: Exam shows a well-appearing large Hispanic male, in no acute distress. He is alert and oriented x3. He is seated in the bed. His temperature is 98.2 degrees, pulse 72, respirations 18, and blood pressure 104/60. The patient has forward flexion of his shoulders bilaterally to about 170 degrees. He does complain of some pain in the left shoulder with this. He does have weakness and pain with resisted external rotation of the left upper extremity. Left upper extremity has 5/5 biceps, triceps strength. His interosseous and grip strength is 5/5 as well. Sensation is grossly intact to light touch in the radial, medial, and ulnar nerve distributions. Biceps reflexes are difficulty to elicit. Evaluation of the right upper extremity shows that he has symmetric range of motion. He has 5/5 external rotation and internal rotation strength. He has no pain with resistance. He has 5/5 strength in his grip and interossei as well as his biceps and triceps. Sensation again is grossly intact to light touch. He has palpable radial pulses bilaterally. The patient denies any neck pain.
His MRI is reviewed. There is evidence of full-thickness tear of infraspinatus and partial tear of the supraspinatus.
IMPRESSION: Left rotator cuff tear.
RECOMMENDATIONS: We will be talking with the patient. We discussed with him his condition can be treated as an outpatient. We explained to him that rotator cuff tear would not explain the numbness in his left upper extremity. Apparently does have evidence of a herniated disk in the cervical spine and this obviously is the more likely cause of his current symptoms. His history of injury a year ago may have been an acute tear of his rotator cuff or may have been acute herniations as well and appears difficult to determine at this point. Again, we do not think there is anything to be done while he is in-house. He can follow up as an outpatient for further treatment, including therapy and/or surgery.
