DOI: 08/06/2014. Patient is a 45-year-old female assembler who sustained a left shoulder injury due to repetitive overhead work. Per OMNI, she underwent a left shoulder surgery on 01/29/15.
Per the Orthopedic IME report by Dr. Best dated 07/02/15, the IW require conservative PT, 1-2 cortisone injections and oral anti-inflammatory medication. Injective therapy by an orthopedic surgeon with conservative care over the next 3-4 week sis recommended. Per the addendum to the Pain Medicine IME report dated 10/20/15 by Dr. Harries, he opined that if the IW remains in pain and endocrine function was presumed to be normal, the next step would be a diagnostic cervical medial branch blocks of the left C4-5, C5-6 and C6-7 facets. If this injection provides greater than 75% pain relief, radiofrequency neurotomy should be considered. …show more content…
She underwent a cervical epidural injection several weeks ago which improved her sharp shoulder pain for 3 weeks by 70% and tingling sensations in the left hand by 50%.
She complains of posterior neck pain which radiates to the anterior lateral aspect of the left arm and fingers. She describes the neck pain as aching with tingling sensations in the arm and hand. Patient also complains of shoulder blade discomfort which is more bothersome than the neck and arm. She describes the shoulder blade pain as sharp in nature. She has undergone physical therapy which provided her with minimal improvement. She has also utilized diclofenac and methocarbamol which did not help either.
She currently rates her pain a 7/10 with feelings of depression, tiredness and
Per the Orthopedic IME report by Dr. Best dated 07/02/15, the IW require conservative PT, 1-2 cortisone injections and oral anti-inflammatory medication. Injective therapy by an orthopedic surgeon with conservative care over the next 3-4 week sis recommended. Per the addendum to the Pain Medicine IME report dated 10/20/15 by Dr. Harries, he opined that if the IW remains in pain and endocrine function was presumed to be normal, the next step would be a diagnostic cervical medial branch blocks of the left C4-5, C5-6 and C6-7 facets. If this injection provides greater than 75% pain relief, radiofrequency neurotomy should be considered. …show more content…
She underwent a cervical epidural injection several weeks ago which improved her sharp shoulder pain for 3 weeks by 70% and tingling sensations in the left hand by 50%.
She complains of posterior neck pain which radiates to the anterior lateral aspect of the left arm and fingers. She describes the neck pain as aching with tingling sensations in the arm and hand. Patient also complains of shoulder blade discomfort which is more bothersome than the neck and arm. She describes the shoulder blade pain as sharp in nature. She has undergone physical therapy which provided her with minimal improvement. She has also utilized diclofenac and methocarbamol which did not help either.
She currently rates her pain a 7/10 with feelings of depression, tiredness and