Dr. Hwang'S Shoulder Intake Form Page 2
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1
2OFFICE USE ONLY:
Patient Chart #________________
INSPECTION:
STABILITY:
MUSCULOSKELETAL:
ABRASION---------Y
N
APPREHENSION:
GAIT--------------------------------
NL ATALGIC
ERYTHEMA------- Y
N
ANT-----------------------
Y
N
DIGITS
NL CLUBBING CYANOSIS FUNGUS
SWELLING-------- Y
N
POST---------------------
Y
N
SKIN:
CONTUSION------ Y
N
RELOCATION:
LESIONS---------------------------
Y
N
PALPATION:EFFUSION _____CC
ANT-----------------------
Y
N
MASSES----------------------------
Y
N
TTP - ACJ / GT / BICEPS/LT
POST-----------------------
CARDIOVASCULAR:
Y
N
- TRAPEZIUS/RHOMBOID
LOAD SHIFT:
PULSES----------------------------
__________________
- _______________________
ANT--------------------------
1 / 2 / 3
EDEMA----------------------------
0 1 2 3 4
ROM:
R ____/____/____/____
ANT/INF--------------------
1 / 2 / 3
AUSCULTATION---------------
__________________
L ____/____/____/____
POST-------------------------
RESPIRATORY:
1 / 2 / 3
TONE: R- - -
L - - -
AUSCULTATION---------------
___________________
STRENGTH:
ABD _____/5
LABRAL:
EFFORT----------------------------
NL ABNL
ER
_____/5
OBRIENS------------------------
Y N POSTERIOR
GI:
____ ABD SOFT
_____BOWEL SOUNDS
IR
_____/5
PRONATION/SUPINATION-
Y N
NEUROLOGICAL:
RC:
IMPINGMENT
_____/3
IMPACTION----------------------
Y N
SENSATION LIGHT TOUCH
NL ABNL
SPEED/YERGESON-------------
Y N
DTR
BICEP--------------
0 1 2 3 4
BR------------------------------------
0 1 2 3 4
CROSS CHEST----------------
Y N
CERVICAL:
CREPITATION----------------
Y N
SCOLIOSIS------------------------
Y
N
____RC ____BI ____ACT ____GH
ROM---------------------------------
NL ABNL
Surgery – SCSC/SCH/Plaza/Willmar
Diagnosis
Bursititis/Impingement
Exam Under Anesthesia
Time L/BC
Rotator Cuff Tendonitis/Tear – Supraspinatus/Subscapularis
Arthroscopy
Acromioclavicular Inflammation
Open
Acromioclavicular Separation
Closed Manipulation
Instability – Anterior/Posterior/Multidirectional
Subacromial Decompression
Biceps Tendonitis
Subcoracoid Decompression
Shoulder Strain/Contusion/Fracture
Distal Clavicle Excision
Adhesive Capsulitis
Rotator Cuff Repair
GIRD
Supraspinatus – Full/Articular/Bursal
Internal Impingement
Infraspinatus – Full/Articular/Bursal
Scapulothoracic Dyskinesis
Subscapularis – Full/Articular/Bursal
Glenohumeral Arthritis
Topaz Microtenotomy
CTA
Biceps Tenodesis/Tenolysis
Debridement Chondromalacia – Humeral/Glenoid
Physical Therapy
Microfracture – Humeral/Glenoid
Home Exercise Program
Capsular Release – Posterior/360 Degree
Evaluate and Treat
1 2 3 4 5 times per week
Major Arthritis Debridement
Strength
for 1 2 3 4 5 6 weeks
Labral Repair – Anterior/Superior/Posterior
ROM
Capsular Tightening – Anterior/Anterioinferior/Posterior
Swelling
Remplissage
Pain
Latarjet/Coracoid Transfer
Ionto
Stimulation
Lipoma Excision
Ultrasound
Massage
Total Shoulder Arthroplasty – Depuy/Biomet/_______________________
Reverse Total Shoulder Arthroplasty – Depuy/Biomet/________________
TENS
TAI
Imaging
MRI
CT
US
Pamphlet, RC, Instability, TSA, Reverse TSA
R/L/B Shoulder
Postop PT Appointment 1-4 Days - SCOA /Other
Arthrogram with Contrast and Lidocaine
Postop Clinic Appointment 10-14 Days
Evaluate
Call clinic and pick up 1-3 days before surgery:
Rotator Cuff
Xray Orbits
Immobilizer/Sling/Slingshot 3
Instability
Follow-up MRI
Ice Machine
Biceps
Call with results
CPM
Cartilage
TENS
Bone
Prescriptions
Adhesive Capsulitis
Percocet 5/325 i-ii po Q4-6 hours PRN#40
Acromioclavicular Joint
Lorcet 10/650 i po Q4-6 hours PRN#30 Refill I
Glenoid Version
Ultracet i-ii po Q4-6 hours PRN#40 Refill I
____________________________________
Toradol 10mg i po Q8 hours PRN#15
Vistaril 10mg i po Q8 hours PRN#20
Mak/forms-sartell/Dr. Hwang Shoulder and Knee HP
(Updated: 3/2012)
DR. HWANG’S SIGNATURE:_____________________________________________
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