Cervical Radiculopathy: A Case Study

Per verification to the provider’s office IW has had 13 PT visits for the back from 10/13/15 through 12/31/15. Requested for recent PT notes, however, no medical records received at the time of submission of the review to PA.

Inspection of the right shoulder joint reveals atrophy. Movements are restricted with flexion to 90 degrees limited by pain and abduction to 75 degrees limited by pain. Hawkin’s test, Neer’s test, Shoulder crossover test, Empty Cans test, Lift-off test, and Apprehension test is positive. On palpation, tenderness is noted in the acromioclavicular joint and subdeltoid

DOI: 8/6/2015. Patient is a 51-year-old female licensed vocational nurse who sustained a work-related injury to her back and hips while moving a client. As per OMNI, she was diagnosed with muscle spasm, pain over the low back and thoracic region. She is status post right carpal tunnel release on 02/26/16.

O: Inspection of the right shoulder, no redness or edema noted; palpation of the right shoulder there was no warmth noted; on deep palpation TM reports in some tenderness

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

The patient notes that the injury happen when he was lifting some metal trash trays into a trash bin when he felt a sharp pain in his shoulders. Treatment history notes that the treatment to date has consisted of medications. Of note, the MRI done showed a large full thickness tear with retraction of the tendon. Physical examination of the left shoulder revealed that the range of motion has forward flexion of 0-175 degrees, external rotation of 0-40 degrees, and internal rotation to T12. There is positive Hawkins’ and Neer’s sign for impingement. There is weakness with abduction testing. Treatment plan notes recommendation, surgical intervention in the form of a left shoulder, subacromial decompression, rotator cuff repair surgery as necessary. A follow up of 2 to 3 weeks if surgery is authorized. As per medical summary and work status dated 6/14/16, it was noted that the patient has not improved significantly and would be needing surgery. The patient’s return to work date is 6/14/16 with no lifting over 10 pounds and no overhead reach. Follow up to clinic date is on

DOI: 3/19/2015. Patient is a 63-year-old right hand dominant male janitor who sustained injury while he was mopping when he began having right shoulder pain. Per OMNI, he was initially diagnosed with right shoulder impingement syndrome, neck strain and right shoulder strain.

DOI: 6/23/2016. Patient is a 42-year-old female registered nurse who sustained injury to her neck/left shoulder when she twisted to keep the attachment from falling to the floor. Per OMNI, she was initially diagnosed with strain to multiple body parts.

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

DOI: 9/26/2015. Patient is a 29-year-old male construction worker who sustained a work-related injury to his neck, back, left shoulder and right knee when he slipped and fell. He is status post left shoulder arthroscopy on 8/05/2016.

The patient was diagnosed with bursitis of the right shoulder, pain in right shoulder, and impingement syndrome of the right shoulder.

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

DOI: 4/27/2015. Patient is a 52-year-old male driver guard who sustained a work-related injury to his bilateral shoulders, hands, wrists, and back after being involved in a motor vehicle accident. As per OMNI, the patient was diagnosed with right shoulder labral tear, biceps tendonitis and impingement syndrome, acromioclavicular sprain, and lumbar disc degenerative disease.

DOI: 6/9/2015. Patient is a 55-year-old right hand dominant male breakfast host employee who sustained injury when he picked up a box of milk when he felt pain on his right shoulder to neck and radiating to the right forearm. Per OMNI, he was initially diagnosed with right shoulder impingement, cervical train and benign hypertension.