Grasser's Case Letter

Based on the orthopedic consultation report dated 03/04/16 by Dr. Strudwick, the patient reports that his symptoms have returned and he has pain at night with elevation, pushing, pulling, reaching and heavy lifting at shoulder level and above.

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

Suffering from the following symptoms depressed mood most of the day, diminished interest and/or pleasure in most all or all activities, significant weight loss (not quite 5% in a month). In addition, he suffers from continuous sleep disruptions of insomnia and hypersomnia, lowered energy levels almost daily, feels like a “peon” and holds on to an inordinate amount of guilt, markedly decreased ability to focus, and most disconcerting of all, recurring thoughts of death. These symptoms were known to be present for the same two-week period and not attributable to a traumatic response (APA, 2013, pp.

Based on the progress report dated 03/10/16, the patient complains of continued pain over the lateral epicondyle. He has completed 3 PT sessions to date with no improvement. Pain is radiating from the elbow towards the shoulder and hand, rated as 8/10. Review of systems is positive for joint pain and bronchitis.

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

Examination by Melissa Kliem, DPT, revealed flexion and extension increased pain in the cervical/lumbar region as well as in his upper extremities. Ms. Kliem noted bilateral hip range of motion was guarded due to increased central thoracolumbar region pain. He also exhibited increased chest pain with

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

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.

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

Based on the progress report dated 08/03/16, the patient continues to suffer from left shoulder pain as well as in the neck, with pain radiating down to the upper back, mid and lower back. Patient is also suffering from pain radiating to both shoulders and hands, as well as numbness and tingling. She has a lot of swelling and inflammation in both hands. Pain is severe and goes up to 8-9/10. Patient reports minimal improvement with medication. She has a lot of difficulty with range of motion of the left shoulder, and with lifting up the shoulder and up in the ear. She has a lot of difficulty doing her activities of daily living.

O: on inspection of the right shoulder, no redness or edema noted; on palpation warmth noted; on deep palpation TM reports increased pain; .Pain with abduction at 70 degrees.

As per consultation notes on 6/30/16, the patient presents for evaluation of his right shoulder. He has not worked for 5 years. His only treatment has been injections which gave him short-term pain relief. He complains of constant right shoulder pain and it keeps him awake at night. It makes it difficult for