DOI: 6/9/2014. The patient is a 51-year-old left-hand dominant female data entry clerk who sustained a work-related injury when she slipped and fell in the parking lot. Per OMNI, she was initially diagnosed with right knee internal derangement, right shoulder rotator cuff tear, right ulnar nerve neuropathy, asymptomatic and cervical spine degenerative multilevel spondylosis.
Per the PT daily treatment note dated 06/17/14, the patient has attended 6 visits for the right shoulder.
Per the panel QME report dated 11/04/15, the patient is not yet at maximum medical improvement (MMI). She is still severely symptomatic and needs further treatment. She is an appropriate candidate for a right shoulder arthroscopy with post-operative course of PT.
Based on the medical report dated 05/09/16 by Dr. Yu, the patient complains of persistent right shoulder pain. Pain is 7-9/10 with overhead activity. On examination of the right shoulder, flexion is painful at 140 degrees and …show more content…
Van Dyke, the patient complains of right shoulder pain which travels to the right arm, forearm and wrist, including the hand/fingers with numbness and tingling from the pinky to elbow. She has marked difficulty lifting her right arm due to stiffness and weakness. On examination of the right shoulder, there is tenderness to palpation of the acromioclavicular joint and subacromial region. Flexion is 100 degrees. Abduction is 90 degrees. Empty Can test is positive for weakness of the supraspinatus. Hawkins-Kennedy and Neer’s impingement tests are positive. Patient was diagnosed with right shoulder internal derangement, possible labrum and/or rotator cuff tear with clinical signs of mild instability of the glenohumeral joint. She would like to proceed with right shoulder arthroscopy. She has failed multimodal conservative care of the right shoulder, which includes medication, PT, acupuncture, activity modification, home exercise program (HEP) and
Per the PT daily treatment note dated 06/17/14, the patient has attended 6 visits for the right shoulder.
Per the panel QME report dated 11/04/15, the patient is not yet at maximum medical improvement (MMI). She is still severely symptomatic and needs further treatment. She is an appropriate candidate for a right shoulder arthroscopy with post-operative course of PT.
Based on the medical report dated 05/09/16 by Dr. Yu, the patient complains of persistent right shoulder pain. Pain is 7-9/10 with overhead activity. On examination of the right shoulder, flexion is painful at 140 degrees and …show more content…
Van Dyke, the patient complains of right shoulder pain which travels to the right arm, forearm and wrist, including the hand/fingers with numbness and tingling from the pinky to elbow. She has marked difficulty lifting her right arm due to stiffness and weakness. On examination of the right shoulder, there is tenderness to palpation of the acromioclavicular joint and subacromial region. Flexion is 100 degrees. Abduction is 90 degrees. Empty Can test is positive for weakness of the supraspinatus. Hawkins-Kennedy and Neer’s impingement tests are positive. Patient was diagnosed with right shoulder internal derangement, possible labrum and/or rotator cuff tear with clinical signs of mild instability of the glenohumeral joint. She would like to proceed with right shoulder arthroscopy. She has failed multimodal conservative care of the right shoulder, which includes medication, PT, acupuncture, activity modification, home exercise program (HEP) and