Esi Right Shoulder Pain Case Study

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.

The patient wants to also update me as far as the arm pain he mentioned last time. He says his left arm is feeling better now. He is noticing that his right shoulder is hurting at times, especially in certain positons such as while he is sleeping and if he has his arm raised over his head while he is lying down. He had no specific injury or trauma. He is not aware of anything that makes it better or worse. He is not using any medication for it thus far. He would be interested in having

S: In 10/22/2014, TM was seen for bilateral shoulder pain. Today TM is here complains of left shoulder pain. According to TM he was aligning a Santfa, a process involving reaching. When he was bring his arm down, he felt the sharp, tearing pain in his anterior of his shoulder. TM is here with left shoulder pain. TM reports his pain at 6-7/10. The pain was sudden, sharp at The pain was localized, and didn’t radiated to anywhere else. The pain was so sudden and so severe, it scared him. TM denies any tingling or numbness, loss of movement.

Client reported this week she is having shoulder pain. She also submitted MRI Rx. With the following findings:

Based on progress report dated 03/09/15, the patient reported of persistent left shoulder pain. She has attended at least 12 PT sessions with non resolution of her symptoms. Due to left shoulder pain with positive impingement test despite 7 weeks of conservative care with NSAIDS, muscle relaxant and PT, left shoulder MRI for further evaluation is recommended. PT for 3 times a week for 4 weeks is also requested. She was advised to continue Anaprox and Flexeril.

This is a 60-year-old male with a 4/16/2015 date of injury. A specific mechanism of injury has not been described.

She also has difficulty breathing. The pain is 5/10-scale level and is aggravated by lifting anything. Heating alleviates the pain. The exam of the elbow was normal except tenderness to palpation over the left ulnar groove and medial epicondyle on the right side. The exam revealed tenderness to palpation over the carpal tunnel, as well as the thenar eminence. On palpation of the joints there was tenderness on the radial and ulnar sides. There was decreased temperature on the left. ROM around the wrists was full and normal. Tinel’s and Phalen’s signs were positive on the left only. Sensory and motor examination was intact and normal. Plan: She may continue with Lyrica 75 mg daily. She has already stopped Meloxicam due to an allergic reaction. Ultracet 37.5/325 mg was prescribed for pain. Acupuncture and MRI are still pending.

12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

Patient was diagnosed with left shoulder pain, status post rotator cuff repair on 07/12/2013, right thigh pain and chronic low back and right lower extremity pain.

DOI: 12/20/2008. The patient is a 42-year old female licensed vocational nurse who sustained a work-related injury when she slipped on ice. As per OMNI entry, she was initially diagnosed with right shoulder impingement and neck strain. She had an AME with Dr. Sanders who found her at MMI as of 03/01/2013. Her future medical care includes medications with no indications for surgery.

The patient states that she continues to have pain, every single day. Her shoulder pain has started to radiate up to her neck. Shoulder pain is rated to a 9/10 without medications, and 5/10 with medication.

Based on the medical report dated 12/20/16, the patient is 5 weeks status post left shoulder surgery. She continues to have pain about the shoulder, though this is decreasing. She takes Norco 5/325 mg 2-3 times per day. She continues with PT and has 7-8 sessions left on the current referral. She performs home exercise program (HEP) continuously

O:Left Wrist: no edema, no discoloration, full ROM, no impairment of the NVS, radial and ulnar pulses +3, pea-sized bump palpated in the dorsal radial border that is firm and stationed and causes pain with pushing on it or extension of the wrist.

Shoulder pain can range from mildly unpleasant to completely debilitating. It can be easy to put off treatment if you don't live within close proximity to a skilled shoulder doctor, but by doing so, you run the risk of having the condition worsen. Founded by Dr. Robert E. McLaughlin, North Shore Shoulder offers world-class orthopedic shoulder care. The facility is based in Beverly, MA, but if you need help with shoulder pain and aren't close enough to come in for an initial consultation, you can send your X-rays, CAT scans, or MRIs in to Dr. McLaughlin for a complimentary review. When doing so, keep the following guidelines in mind: