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
According to operative report dated 3/4/2016, patient underwent right medial epicondyle debridement. Based on the medical report dated 12/22/16, the patient was last seen on 10/13/16, and was recommended to have continued therapy. He has not had therapy secondary to insurance issues over the last month or so. He presents with ongoing right elbow pain status post cubital tunnel release and medial epicondylitis debridement, worsening with motion and activity, lifting, reaching, bending, upper extremity dressing, household
some of his overwhelming anxieties that were no longer controllable through routine or tasks. He is on the less restrictive amount of medication that is overall effective.
Client has only been taking the medication for a few days and primary care provider referred client to counselor. Client did not report any other medical issues that she might be experiencing at this time. Client participated in the session by answering questions that were asked. The client was oriented and alert. Client appeared to be appropriately dressed and groomed. Client spoke in a low sad tone and cried frequently throughout the session. Client spoke with a normal rate of speech. Client appeared to have an average I.Q and could recall memories from her past easily. The client was in a sad and depressive mood as evidenced by crying and lowering her head. The client had thoughts of not wanting to be here and feeling zoned out. The client consistently blamed herself for her husband leaving and repeatedly stated that she was not a good
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
This essay takes a glimpse into the comorbidity and condition in which a person diagnosed alcohol use disorder and depressive disorder concurrently. I diagnosed Anthony (a hypothetical patient) first with alcohol use disorder, however, it soon became apparent that there was something more menacing and complex going on with
Patient is diagnosed with pain disorder with related psychological factors and complex regional pain syndrome I of the right upper limb, chronic pain syndrome. He will follow-up in 4 weeks.
As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has
Per the medical report dated 06/13/16, treatment to date includes He reports no major changes in his condition, since his last visit. His pain is rated as 3-6/10, described as dull, hard, aching or worse. Pain is increased with sitting, standing, walking, lifting, looking up and down, turning to the sides, bending, and twisting. He is unable to work. He is very limited physically. He has to modify or avoid social and recreational activities to manage the pain. He feels like his quality of life is severely affected. His pain is 80% in the neck and 20% in the upper extremities, mostly on the
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.
DOI: 06/04/2007. Patient is a 66-year-old male baggage service agent who felt pain in his right shoulder after lifting bags. As per OMNI notes, patient is status post right shoulder decompression. Per the Orthopedic AME Supplemental report dated 11/05/19, IW has 3% whole person impairment rating for his bilateral shoulders.
Per the initial orthopedic evaluation report dated 02/09/16, the patient’s pain is worsened when he attempts to elevate the arm. Pain and weakness in his arm make it difficult for him to perform activities such as dressing, grooming and bathing. He is taking
O: No discoloration or edema noted in his right shoulder or right bicep and antecubital.
Per the QME report dated 08/21/14 by Dr. Hurria, the patient has a calculated total whole person impairment grating of 33%. Diagnoses include arthritis of both hips, status post right total hip replacement, cervical/lumbar sprain, radiculopathy to both upper and lower extremities, right cubital tunnel syndrome and impingement of both shoulders. Future medical treatment includes decompression of both shoulder, transfer of the anterior ulnar nerve
DOI: 09/06/2013. This is a case of a 57-year-old female biometric technician who sustained a work-related injury to her right shoulder when she grabbed an elderly gentleman with her right arm to prevent him from falling or hitting his head. As per OMNI entry, patient was diagnosed with shoulder strain. Per progress report dated 4/26/2016, patient presents for follow up evaluation and continues to complain of constant right shoulder pain over the acromioclavicular joint. Patient had two intra-articular steroid injections that provided significant relief. She is requesting for an additional shot at the time of visit. She rates her pain at 7/10 on a pain scale. Patient reports that Norco relieves the pain at 4/10 for 3-4 hours with received therapy