Esi Right Shoulder Pain Case Study

2. During inspection of the patient’s affected shoulder, name at least three key clinical aspects that you need to observe on both shoulders that would suggest any pathology or abnormality on the shoulders. From the three clinical aspects that you observed, explain what each of the findings would indicate concerning the pathology of the shoulder. For example if the shoulder is

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

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.

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

Neck. Trachea midline. Thyroid not palpable. Full shoulder strength with light resistance applied. ROM complete without pain.

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.

~Chief Complaint: The patient c/o bulging to the right shoulder possible dislocation with 7/10 localized pain x2 day. The patient states that when she woke up Tuesday she had right shoulder pain with mild swelling and bulging that appear to be her bone. The pain states that she is able to move he arm but it is extremely pain. The patient states that she has been taking Advil and icing her shoulder with very little improvement. She denies possible injury or numbness and tingling in the right arm or hands

Diagnoses are cervical radiculopathy, right shoulder pain, nondisplaced fracture of the greater tuberosity of the right humerus and right shoulder bursitis. He has reached maximal recovery for his right shoulder. MD is concerned that the elbow and hand pain are related more to his neck as he has a history of cervical radiculopathy and his symptoms are more of tightness than pain that can be localized. He has had epidural injections in the past for left sided radiculopathy. An updated MRI is requested. If there are right-sided findings, he will be sent for possible injection for the upper extremity pain. Otherwise, he will be sent for a second opinion for his continued

S: TM completed total of 4 ESI visits for her right elbow Strain. TM reports ESI’s heat treatment is helping her with symptom’s management. TM reports her pain 5/10. Her pain starts at her elbow and radiates to her forearm, and reports weakness in her grip strength in her right hand. TM also reports her right elbow pain radiates up to her right shoulder (?) TM denies her right arm pain wakes her up at night.

According to the orthopedic QME on 7/9/13, future medical care includes inflammation medicine, occasional pain medication, muscle relaxants, occasional injections, left shoulder surgery, physical therapy and occasional orthopedic doctor visit. Additional physical therapy has been included in the patient’s future medical care on 11/6/14 evaluation.

S: TM completed total of 28 ESI visits for his Left Upper Trapezius Strain that started in 8/25/2016. TM reports his pain at rest is 1-2/10; tightness, but with movement at work his pain can be up to 7/10. The pain is gradual as the shift progresses. ESI help him with manage his symptoms. For the fast couple of weeks, heat and the light massage of his left upper trapezius has improved his current condition. TM denies cervical neck pain, radiating pain, tingling, numbness, or loss of movement in his upper extremities. TM is not taking naproxen or acetaminophen as ordered.

related injury to his right shoulder when a bathroom stall door struck him. As per OMNI entry, he is status post right shoulder repair on 09/23/2011 and repeat shoulder surgery on 03/23/2012. The patient was subsequently diagnosed with shoulder impingement syndrome, right. AME dated 1/12/16, future medical provisions states that the left knee will be treated conservatively including anti-inflammatories and perhaps periodic intra-articular cortisone injections. Viscoelestic supplementation is not recommended. It is also stated that it is reasonable to obtain a spinal consultation with someone such as Dr. Jones, Dr. Herron, or Dr. Hutchinson. The prior lumbar MRI scan (6/27/14) demonstrates instability and stenosis, so it is recommended for an

\DOI: 3/11/2016. Patient is a 52-year old male supervisor who sustained a work related injury to his right elbow and tore his muscle when he tries to grab a falling 'A' frame. As per medical report dated 5/3/16, patient suffered biceps tendon tear. It was noted that the patient had surgery performed on 3/25 and he is in the process of going through physical therapy. He continues to have limitations in range of motion of the elbow. He also has developed fluid and edema over the right elbow into the olecranon bursa. He has an extension lag of about 15 degrees. He can flex his elbow, but not fully. There is about 5-6 inches between his fingertips and his shoulder. He also cannot perform full supination and pronation. It is in the moderate range at this time.

TM report her right shoulder pain is improving with ESI. According to TM, she would like to avoid any type of surgery or referral back to Dr. Walcott, if it can be managed in the HMMA clinic. TM rates her pain is 4/10, aching like pain and it is localized to her right shoulder AC joint

Based on the medical report dated 08/12/15, the patient complained of pain to her left shoulder and arm, rated as 5-8/10 and is 75% present of the time. Treatments to date include pain medications, braces/casts, multiple sessions of PT and surgery. Current medications include Diclofenac, Hydrocodone-APAP, Tylenol, Advair and Albuterol. On examination, the IW has restricted range of motion in extension, abduction and internal rotation of the left shoulder. The restrictions above the shoulder girdle include the trapezius, levator scapula and rhomboids. It was noted that the IW’s “COMM” score is 4, Opioid Risk Tool score is 1, CAGE AID is negative and PHQ-9 score is 0, and schedule II record and CURES report reviews were consistent.