Family Medicine Specialist Note (Canada)

ICD-9 Diagnostic Codes

• 726.10 - Rotator cuff syndrome of shoulder and allied disorders (Right shoulder pain)
• 401.9 - Essential hypertension, unspecified (Hypertension follow-up)
• 250.00 - Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled (T2DM routine review)

Billing Codes

• 5B - Partial Assessment ($36.70)
• 659A - Chronic Disease Management: Diabetes Mellitus ($65.00)

Subjective

• 58 yo M presents with 3-week history of dull R anterolateral shoulder pain. Insidious onset after painting a ceiling. Pain worse with overhead reaching and sleeping on R side. No acute trauma, neck pain, or radicular sx. Also here for routine T2DM and HTN review; home BP averaging 145/88 mmHg.
• PMHx: T2DM (dx 2018), HTN, dyslipidaemia. PSHx: Laparoscopic cholecystectomy (2015).
• Meds: metformin (Glucophage®) 1,000 mg PO BID, ramipril (Altace®) 5 mg PO daily, rosuvastatin (Crestor®) 10 mg PO daily, ibuprofen (Advil®) 400 mg PO PRN.
• SocHx: Works as a carpenter (R-hand dominant). Non-smoker, 2-3 ETOH drinks/week. Lives with spouse.
• Allergies: Penicillin (maculopapular rash).

MSK: Positive for R shoulder pain and decreased ROM. Negative for joint swelling or distal paraesthesia. CVS: Negative for chest pain, palpitations, SOB, or orthopnoea. Endo: Negative for polyuria, polydipsia, or hypoglycaemic episodes.

Objective

• Vitals: BP 148/90 mmHg, HR 74 bpm, Temp 36.7 °C, Wt 89.5 kg, BMI 28.4 kg/m². Gen: Alert, NAD. CVS: S1 S2 normal, no murmurs, no peripheral oedema. R Shoulder: No visible deformity, erythema, or muscle wasting; tenderness over R subacromial space; active abduction painful between 70-120 degrees; passive ROM full; NV intact distally; 5/5 strength globally, except 4/5 supraspinatus secondary to pain.
• Positive Neer and Hawkins-Kennedy impingement signs on R. Empty can test painful, no true drop arm. Speed's test negative.
• Labs (14/05/2024): HbA1c 7.1%, FBG 6.8 mmol/L, Cr 82 umol/L, eGFR 88 mL/min, K+ 4.4 mmol/L, ACR 1.2 mg/mmol, LDL 1.8 mmol/L.

Assessment & Plan

1. Right shoulder pain

• Rotator cuff tendinopathy
• DDx: Subacromial bursitis, partial rotator cuff tear, AC joint osteoarthritis
• Order R shoulder X-ray (AP, transscapular Y, axillary views) and R shoulder US if no improvement in 6 weeks
• Advise relative rest, avoid overhead heavy lifting. Start naproxen (Naprosyn®) 500 mg PO BID with food for 10 days (stop ibuprofen). Discussed subacromial corticosteroid injection if refractory
• Refer to physiotherapy for rotator cuff strengthening and scapular stabilization

2. Hypertension

• Essential hypertension
• Repeat electrolytes and Cr in 3 weeks
• Increase ramipril (Altace®) to 10 mg PO daily. Continue home BP monitoring, target < 130/80 mmHg

3. Type 2 diabetes mellitus

• Type 2 diabetes mellitus
• Repeat HbA1c in 6 months
• Glycaemic and lipid targets met. Continue metformin (Glucophage®) 1,000 mg PO BID and rosuvastatin (Crestor®) 10 mg PO daily
• Advise routine annual optometry diabetic retinal exam

Recorded with an AI scribe. Patient consent obtained.