DOI: 4/24/2015. Patient is a 47-year-old right hand dominant female patient service representative who alleged right shoulder pain from repetitive duties. Per OMNI entry, she was initially diagnosed with right rotator cuff tendinitis.
Per the doctors first report of occupational injury dated 04/24/15, patient was given a home exercise program. She was given prescription for Voltaren gel and place d on modified duty with work restrictions. She was told to apply ice/heat to the area.
MRI of the right shoulder obtained on 08/05/15 demonstrates mild subacromial subdeltoid bursitis in the setting of moderate rotator cuff tendinosis, but without high-grade partial tear or lateral subacromial spur. There is scarring of the biceps pulley within the rotator cuff interval and also suspected affecting the anterior …show more content…
Arora, the patient has had off and-on pain since April 2016. She did not report any traumatic event, but the pain level is to the point where she is unable to do activities of daily living and her work is being affected. Her pain level is described as being 5/10 pain. She constantly has pain going into the lateral portion of the right shoulder and over the anterior portion, and she has occasional numbness and tingling into the small and ring fingers.
The patient has had a total of five injections in the shoulder as well as physical therapy over 10 sessions.
The patient is currently taking levothyroxine, Oracea and ranitidine.
On examination of the right shoulder, there is positive pain over the acromioclavicular joint with palpation.
Active forward elevation is 120 degrees. Active external rotation is 40 degrees. Abduction is 100 degrees. Internal rotation is to L3. There is positive pain with impingement profile with positive Neer’s and Hawkin’s tests. She has a positive cross arm test with pain.
Of note, X-ray examination showed some acromioclavicular joint arthritis; otherwise benign looking
Per the doctors first report of occupational injury dated 04/24/15, patient was given a home exercise program. She was given prescription for Voltaren gel and place d on modified duty with work restrictions. She was told to apply ice/heat to the area.
MRI of the right shoulder obtained on 08/05/15 demonstrates mild subacromial subdeltoid bursitis in the setting of moderate rotator cuff tendinosis, but without high-grade partial tear or lateral subacromial spur. There is scarring of the biceps pulley within the rotator cuff interval and also suspected affecting the anterior …show more content…
Arora, the patient has had off and-on pain since April 2016. She did not report any traumatic event, but the pain level is to the point where she is unable to do activities of daily living and her work is being affected. Her pain level is described as being 5/10 pain. She constantly has pain going into the lateral portion of the right shoulder and over the anterior portion, and she has occasional numbness and tingling into the small and ring fingers.
The patient has had a total of five injections in the shoulder as well as physical therapy over 10 sessions.
The patient is currently taking levothyroxine, Oracea and ranitidine.
On examination of the right shoulder, there is positive pain over the acromioclavicular joint with palpation.
Active forward elevation is 120 degrees. Active external rotation is 40 degrees. Abduction is 100 degrees. Internal rotation is to L3. There is positive pain with impingement profile with positive Neer’s and Hawkin’s tests. She has a positive cross arm test with pain.
Of note, X-ray examination showed some acromioclavicular joint arthritis; otherwise benign looking