A 45-year-old female established patient with fibromyalgia returns to the office for a follow-up visit. The patient complains of tenderness in the right shoulder. She took ibuprofen, which eased the pain earlier, but the pain is intensifying. On a scale of one to 10, the patient indicated that the pain level was an eight. It was noted that there was no change in her past family history since her last visit.
The physician performed an expanded, problem-focused history as well as an expanded, problem-focused exam. The medical decision-making was straightforward. The physician decided to give the patient two trigger-point injections in her right shoulder muscle. The patient is injected with 20 mg of lidiocaine and scheduled for a return visit in three weeks.
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