DOI: 6/13/2012. Patient is a 64-year-old female customer service representative who sustained a work-related injury when she slipped and fell while she was going down the stairs. Per OMNI, she was initially diagnosed with closed fracture of the upper end humerus, and adhesive capsulitis of the left shoulder. Internal QME Dr. Sachs deemed that she has reached permanent and stationary status last 6/17/15. She is post-op left shoulder surgery on 6/29/15.
Based on the medical report dated 07/07/16 by Dr. Thompson, the patient complains of pain to her bilateral shoulders, arms and hands. Pain is rated as 4/10 with medication and 7/10 without medication.
Left shoulder pain is described as achy, shooting, tingling and numb, rated as 5-6/10. Pain is worse with use of the …show more content…
She is also taking omeprazole, lisinopril, alendronate, stool softener and Motrin from other providers.
Patient was diagnosed with adhesive capsulitis of the shoulder, rotator cuff syndrome and chronic pain syndrome, all worsening. Use of Tylenol and Relafen reduces pain from 8/10 to 4/10, and allows for increase in activity tolerance, improves activities of daily living including housework and dressing. No side effects are reported. Patient complains of constipation which is very bothersome, and Senokot-S 8.6 mg 1-2 tablets daily # 60 trial was recommended.
She was given a prescription for trazodone 50 mg 1-2 tablets at bedtime #60 with 1 refill for chronic pain and pain related insomnia as it improves sleep, allowing for increased in daytime activity, Tylenol ES 500 mg 1 tablet daily as needed #15 with 1 refill as it decreases pain by 50% and improves activity tolerance with no side effects and Relafen 500 mg 1-2 tablets daily as needed #60 with 1 refill as it decreased pain by 50%, improves activity tolerance and reduces muscle soreness, with no side effects. Next appointment is in 6
Based on the medical report dated 07/07/16 by Dr. Thompson, the patient complains of pain to her bilateral shoulders, arms and hands. Pain is rated as 4/10 with medication and 7/10 without medication.
Left shoulder pain is described as achy, shooting, tingling and numb, rated as 5-6/10. Pain is worse with use of the …show more content…
She is also taking omeprazole, lisinopril, alendronate, stool softener and Motrin from other providers.
Patient was diagnosed with adhesive capsulitis of the shoulder, rotator cuff syndrome and chronic pain syndrome, all worsening. Use of Tylenol and Relafen reduces pain from 8/10 to 4/10, and allows for increase in activity tolerance, improves activities of daily living including housework and dressing. No side effects are reported. Patient complains of constipation which is very bothersome, and Senokot-S 8.6 mg 1-2 tablets daily # 60 trial was recommended.
She was given a prescription for trazodone 50 mg 1-2 tablets at bedtime #60 with 1 refill for chronic pain and pain related insomnia as it improves sleep, allowing for increased in daytime activity, Tylenol ES 500 mg 1 tablet daily as needed #15 with 1 refill as it decreases pain by 50% and improves activity tolerance with no side effects and Relafen 500 mg 1-2 tablets daily as needed #60 with 1 refill as it decreased pain by 50%, improves activity tolerance and reduces muscle soreness, with no side effects. Next appointment is in 6