Diagnosis : Impingement Syndrome, Right Shoulder

752 Words Feb 23rd, 2016 4 Pages
This is a 60-year-old male with a 4/16/2015 date of injury. A specific mechanism of injury has not been described.

DIAGNOSIS: Impingement syndrome, right shoulder; full-thickness rotator cuff tear with retraction, right shoulder; adhesive capsulites, right shoulder; post-op pain, right shoulder; Right elbow strain/sprain; Right wrist strain/sprain; Right upper extremity overuse syndrome.

02/16/16 Progress Report noted that the pain is very severe in the right upper extremity at a 7-8/10-scale level. She is using the Pulley to exercise shoulder, but it is making her shoulder hurt worse. She is working with modified duties in a thrift store, but it requires her to do repetitive tasks such as sorting and hanging items. She is having triggering in the middle and ring fingers of her right hand. Objective findings: right upper extremity flexion 50, extension 50, radial deviation 15 and ulnar deviation 20. There were positive Tinel’s and Phalen’s signs. Finkelstein sign was negative. There was tenderness to palpation over the right trapezius. Right Shoulder flexion was 120, extension was 40, Adduction was 35, Abduction was 130, Internal rotation was 60, and external rotation was 75. Motor Strength: Deltoid 4/5, Biceps 4/5, and Triceps 5/5. There was intermittent palpable triggering in the right 3rd and 4th fingers. Plan: evaluation & management; wrist brace splint; acupuncture 2X4 right shoulder; Occupational therapy right wrist/hand; New Treatment-Tramadol 50 mg 1 tab tid and…
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