General: alert, well developed, well nourished

Head: non-traumatic, normocephalic

Eyes: PERRL, normal conjunctiva and lids; no discharge, erythema or swelling, no scleral icterus
Ears: normal external appearance
Nose: normal appearance
Mouth: mucous membranes moist, normal tonsils and oropharynx
Neck: supple, nontender, normal ROM
Lymph nodes: no lymphadenopathy
Chest: Normal
Lungs: clear to auscultation, with good air entry throughout. No wheezes, crackles, or stridor.
Cardiac: regular rate and rhythm, normal S1 and S2, no murmur
Abdomen: soft, no tenderness, distention, masses, or organomegaly; bowel sounds present
GU: deferred
Skin: more edematous appearing on left arm/forearm, otherwise no rashes or jaundice
Back: spinous process tenderness none
paravertebral tenderness none
facet loading negative
straight leg raising negative
Patrick's maneuver negative
Trigger points are not identified
Musculoskeletal/Extremities: decreased range of motion in left shoulder and left elbow
Neurologic:appropriate for age except as noted below:
Sensory: decreased light touch in the left shoulder

ASSESSMENT
Chase is a 16 y.o. male who appears to have left humerus tumor pain. This visit is a preop evaluation
of left shoulder amputation for 8/29. We discussed pathophysiology, prognosis, the effects of the
phantom limb pain on Chase, the range of therapies and the need for Chase to approach the
recommended therapies wholeheartedly for best results. The patient and family are interested in
pursuing the modality-based plan as recommended. Therefore we will proceed with our plan.

PLAN

1. Continue gabapentin regimen as follows:

Take 1 tab (300mg) once a day before sleep for today.
Take 1 tab (300mg) twice a day, (in the morning when wakes up, and in the evening before sleep)
from 8/24 to 8/26.
Take 1 tab (300mg) three times a day, (in the morning when wakes up, around noon time after lunch,
and in the evening before sleep) from 8/27 to 8/29.
2. Continue to take delsym at 5ml (30mg) orally twice a day.
3. Continue vitamin C 1 tab (1000mg) orally once a day.
4. Continue using oxycodone 1tab (10mg) prn for pain.
5. Discussed the wean plan for these medication after surgery.
6. Counseling provided on phantom limb pain, adherence on medication.
7. Notes will be provided for school after surgery so he can take medication during school.
Return to pain clinic after surgery with Dr. Rose on 9/19 or NP clinic within 1-2 weeks after surgery if
he needs to be seen earlier.