History & Physical

Chief complaint: Arm and shoulder pain X 2 years


41 y/o G1P1 female presents to her primary care physician for her annual physical and has complaints of right arm pain. She mentions her right arm has been swollen and painful on and off for 2 years now. The past month the patient has been having the most pain with her right arm, forearm, medial & lateral epicondyle, and shoulder. She says has poor grip, difficulty holding objects and cannot drive with the right arm. Patient mentions she has had a bulging disc in that area of her back for 4-5 years as well. She also mentions that has no energy and hot flashes. She was seen by her pain management doctor but was not given anything for her pain. Last OB/GYN appointment was Sept 2022 for removal of tumor in her uterus. Pt. denies headache, shortness of breath, fever, chills, chest pain, dysuria, cough, nausea, or vomiting.

Past Medical History


Immunizations: up to date; Covid vaccine Pfizer X 3 and took the Flu vaccine back in November 2023

Past surgical history

Removal of uterine tumor September 2022 – Jamaica hospital


Omeprazole 20 mg oral tablet – 1 tablet taken by mouth daily



– Food allergy: None

– Denies seasonal allergies

Family history

– Father, 67 – alive and well

– Mother, 65 – DM2, HTN, CAD

– Maternal cousin – early 40s had breast mass

– Children, one daughter – 16 years-old, alive, and well

Social History

Mrs. A is living in an apartment with her husband and daughter in Queens, NY.

Habits: denies drinking alcohol, smoking cigarettes, or using illicit substance abuse. She does mention that she smokes marijuana occasionally.

Travel: Pt has not traveled recently

Diet: She makes her meals at home. She eats protein dishes as well as making salads.

Exercise: Walks around the neighborhood for about 60 minutes a day

Occupation: Currently unemployed

Safety measures: Puts on her seatbelt when she drives in a car

Sleep: reports that she sleeps about 6 hours a night

Sexual history: Is sexually active with one partner, her husband, and has no history of STI’s


General – denies fever, fatigue, weight loss and weakness

Skin, Hair, Nails – denies any change in hair texture, excessive dryness or sweating, discolorations, pigmentations, rashes, or pruritus

Head – denies losing unconsciousness, headache or being lightheaded currently.

Eyes – denies visual disturbances, blurry vision, fatigue, lacrimation, photophobia, or pruritus.

Nose/sinus – denies obstruction, discharge, or epistaxis.

Ears – denies deafness, pain, discharge, tinnitus, or hearing aids.

Mouth/throat – denies bleeding gums, sore tongue, mouth ulcers, voice changes or denture use.

Neck – denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – denies lumps, nipple discharge, or pain.

Pulmonary system – Denies orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea.

Cardiovascular system –Denies palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur, chest pain or hypertension.

Gastrointestinal system – Denies vomiting, decreased appetite, pyrosis, flatulence, eructation, flank pain, diarrhea, jaundice, change in bowel habits, constipation, abdominal pain, pelvic pain, rectal bleeding, or dysphagia

Genitourinary system – Denies incontinence, change in urine color, polyuria, dysuria or nocturia

Menstrual/obstetrical – G1P1. Denies any abnormalities such as vaginal bleeding, vaginal discharge, vaginal itching, or dyspareunia.

Nervous – Pt is complaining of loss of arm strength. Denies weakness, sensory disturbances, or seizures.

Musculoskeletal system – Pt is complaining of right arm and forearm pain and swelling. Denies redness, back pain, or arthritis.

Peripheral vascular system – denies intermittent claudication, trophic changes, varicose veins, peripheral edema, or color changes.

Hematologic system – denies easy bruising and bleeding, anemia, lymph node enlargement, blood transfusions, or h/o DVT/PE.

Endocrine system – denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies helplessness or hopelessness, anxiety, depression, and a history of seeing a mental health professional, lack of interest in usual activities, suicidal ideation, or OCT.

Physical Exam

General: Female in her 40’s is awake, alert, and oriented x 3 and in no acute distress. She is dressed appropriately for the weather and has a good affect and mood.

Vital signs:

– BP: L: 113/78 mm/Hg

– Respiratory rate: 16 breaths/min, unlabored

– Pulse: 80 beats/min, regular

– Temperature: 97.9 degrees F (oral)

– O2 sat: 100% room air

– Height: 61 inches

– Weight: 174 lbs

– BMI: 32.9

Skin – No bruising was noted on the patient. Good turgor. No tenting. Normal body temperature was noted. Non-icteric

Hair – Average quantity and distribution. No nits or lice were seen; no seborrhea was noted

Nails – No clubbing was seen; cap refill was under 2 seconds. No splinter hemorrhages, lesions, swelling nor any beau’s lines were noted. Atraumatic.

Head – Normocephalic, atraumatic and non-tender to palpation.

Eyes – Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctive pink.

Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus

Ears – Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge, bleeding or foreign bodies in external auditory canal AU. Some cerumen was noted bilaterally. TM’s pearly-white, intact with cone of light in normal position AU.

Nose – Symmetrical nares with no masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa pink. No discharge noted on anterior rhinoscopy. Septum midline without any lesions, deformities or perforation. No foreign bodies.

Sinuses – Non tender to palpation and percussion over bilateral frontal and maxillary sinuses.

Lips – Pink, moist with no cyanosis or masses noted. Non-tender to palpation.

Oral Mucosa – Pink and well hydrated. No masses, lesions or leukoplakia noted.

Palate – Pink and well hydrated. No masses or lesions noted.

Teeth – Good dentition with a couple of filled cavities noted.

Gingivae – Pink and moist. No hyperplasia or masses.

Tongue – Pink, well papillated. No masses, lesions or deviation noted.

Oropharynx – Well hydrated with no erythema, exudates, masses, or lesions. Tonsils are present with no erythema or exudates. Uvula midline with no lesions noted.

Neck – Trachea midline. No masses, lesions, or scars noted. Supple and non-tender to palpation. Full range of motion. No palpable cervical adenopathy.

Thyroid – Non-tender, no thyromegaly. No palpable nodules nor any bruits noted.

Chest – Symmetrical, no deformities and no trauma noted. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout

Lungs – Symmetrical expansion with respiration. No intercostal retractions, or tenderness. Breath sounds clear to auscultation bilaterally. No rales/wheezes/rhonchi auscultated. No fremitus noted.

Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdomen – Non-distended, soft and non-tender. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No palpable masses or organomegaly. No inguinal hernia. No palpable lymphadenopathy. Costovertebral angle nontender.

Breast Exam: Normal and symmetric appearance. No nipple discharge or retraction. No skin dimpling. Positive, well demarcated and palpable left breast mass at 3 o’clock 3cm from the nipple.

Mental status exam: Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.

Motor/Cerebellar: Moderate swelling and tenderness are noted on the medial epicondyle of both elbow joints. Muscle strength of upper extremities show 3/5 flexor strength and 3/5 for extensor strength. There is decreased grip strength (3/5) of both hands. There is active ROM of both elbow joints. Full active/passive ROM of all other extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 of lower extremities. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, and no asterixis

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted. No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy.

Assessment: 41 y/o G1P1 female, with PMHx of GERD, presenting to her PCP with bilateral arm and shoulder pain. Bilateral medial epicondyle swelling and tenderness was noted with decreased bilateral muscle and grip strength. An unspecified palpable mass was found on the L breast at 3 o’clock 3cm from the nipple.

Plan: Blood work will be taken from the patient including CBC, CMP, TSH, and full hormone blood panel, as well as a UA. A referral will be given for her OB/GYN to do her pap smear and to get left-sided ultrasound and bilateral mammogram. A referral will be given to get another pain management doctor. A referral will be given to get an orthopedic doctor to investigate her bulging disk which might be the reason for her arm/shoulder pain. Pain medication will be prescribed (Ibuprofen 600 mg oral tablets three times daily with food or milk). Genetic blood testing for BRCA was mentioned, but patient declined to be tested today.

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