REASON FOR VISIT: Right olecranon bursitis, 2-week recheck.
SUBJECTIVE: The patient presents to the office today for recheck on his right olecranon bursitis. The patient states it is much better. The patient does not have any pain with it. He has no erythema. No warmth. The patient states that it has gone down. The patient can actually feel the bone in his elbow now. The patient has no other complaints today.
CURRENT MEDICATIONS: The patient is on amlodipine 5 mg, aspirin 81 mg, atenolol 25 mg, losartan 50 mg daily, multivitamin, naproxen every 12 hours and simvastatin 20 mg.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nonsmoker.
OBJECTIVE: VITAL SIGNS: The patient’s weight is 192.6 pounds, height 5 feet 8 inches, and BMI is 29.3. Pulse is 74, respirations are 12, and blood pressure is 130/80. GENERAL: The patient looks well and is in no respiratory distress. HEENT: Eyes: Conjunctiva are clear bilaterally. Extraocular motions are normal. Ear (Right): No erythema, no fluid. Canals are normal. Ear (Left): No erythema, no fluid. Canals are normal. Nose: Patent. No erythema. No sinus tenderness. Pharynx: No erythema. No tonsillar enlargement. No exudate. No ulcers. NECK: Supple. No nodules. LUNGS: Clear. No rhonchi, wheezes or rales. HEART: Normal sounds. No murmurs, no clicks, no gallops appreciated. ABDOMEN: Normal sounds in all 4 quadrants. No tenderness. No hepatosplenomegaly. EXTREMITIES: The right upper extremity does show that he has a small pocket of fluid in the posterior portion of the olecranon bursa. However, no erythema, no warmth, and the joint is really palpable.
ASSESSMENT: Olecranon bursitis, resolving.
PLAN:
1. The patient will continue with naproxen only, p.r.n. with food.
2. Anticipate total clearing. If not, within the next 2 to 3 weeks, he should call us and update. The patient has a followup appointment already scheduled with Dr. John Doe.
