DOI: 7/1/2015. Patient is a 63-year-old female nursing assistant who sustained injury to her left shoulder while helping to move a patient. Per OMNI entry, she was initially diagnosed with adhesive capsulitis of the left shoulder, in the setting of a bursal-sided partial rotator cuff tear. IW underwent a left shoulder arthroscopic capsular release, bursal release, and subacromial decompression on 11/16/16.
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
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A corticosteroid injection was administered to the glenohumeral joint. She should continue with therapy and home exercise program (HEP).
Per the PT note dated 12/27/16, patient states doing home exercise program (HEP) 3 times daily, though she still has difficulty with range of motion (ROM) of the left upper extremity. Patient has attended 4/12 sessions.
On examination, ROM of the glenohumeral joint shows flexion of 105 degrees and passive ROM of 110 degrees. Active ROM has improved since evaluation.
Manual muscle testing of the left glenohumeral joint with flexion, abduction and external rotation is 4/5. Patient is with limited use of the left upper extremity and has slow progress noted with precautions of pacemaker limiting aggressive stretching. Plan is to progress with ROM and mobility strength.
Per OMNI payment screen, patient has attended approximately a total of 14 post-operative PT sessions for the left shoulder from 11/22/16 to 12/27/16. Per the Request for Authorization form dated 01/12/17, request is for additional 12 sessions, 2 times per week for 6 weeks to bring total to 24 sessions.
Current request is for 12 Physical Therapy Visits for the Left Shoulder between 1/17/2017 and
DOI: 11/24/2011. The patient is a 48-year-old female home health aide who sustained injury while turning a patient in bed to put a clean pad when the bed moved. Per OMNI, the patient is diagnosed with L4-5 disc herniation with annular tear and left knee radicular syndrome. She has undergone posterolateral and interbody fusion at L4-5 on 02/18/2013.
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
DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.
The patient notes that the injury happen when he was lifting some metal trash trays into a trash bin when he felt a sharp pain in his shoulders. Treatment history notes that the treatment to date has consisted of medications. Of note, the MRI done showed a large full thickness tear with retraction of the tendon. Physical examination of the left shoulder revealed that the range of motion has forward flexion of 0-175 degrees, external rotation of 0-40 degrees, and internal rotation to T12. There is positive Hawkins’ and Neer’s sign for impingement. There is weakness with abduction testing. Treatment plan notes recommendation, surgical intervention in the form of a left shoulder, subacromial decompression, rotator cuff repair surgery as necessary. A follow up of 2 to 3 weeks if surgery is authorized. As per medical summary and work status dated 6/14/16, it was noted that the patient has not improved significantly and would be needing surgery. The patient’s return to work date is 6/14/16 with no lifting over 10 pounds and no overhead reach. Follow up to clinic date is on
01/13/16 Progress Report noted that the patient underwent ORIF with rod placement. He was cleared by ortho to start PT on 08/04/15. He still has decreased ROM and difficulty with ambulation. He does need to continue PT to improve his functional performance, so he can successfully return back to work.
Even with active assistance, the patient can only achieve approximately 140 degrees of forward elevation, 60 degrees of external rotation, and internal rotation barely to his upper sacrurn. He has 4/5 supraspinatus weakness and pain. Internal and external rotation strength seems to be normal. He has a nonspecifically painful Neer’s, Hawkins, and O’Brien’s test. His proximal biceps and acromioclavicular (AC) joint are both very tender to palpation.
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
MRI of the right shoulder report dated 03/04/14 revealed tear of the supraspinatus/infraspinatus tendon and subscapularis tendon. There is tendinosis of the teres minor. Abnormal signal is noted within the biceps tendon concerning for tear. Degenerative changes involving humeral head are seen. Bone marrow edema is noted involving the superior lateral aspect of the humeral head and the glenoid bone. Degenerative changes at the glenohumeral joint and the acromioclavicular joint are noted. There is edema and sclerosis of the posterior glenoid. Abnormal cortex of the posterior glenoid is demonstrated
DIAGNOSIS: Strain of muscle, fascia, and tendon at neck level; Carpal tunnel syndrome, unspecified right limb,;Carpal tunnel syndrome, unspecified left limb; Status post left carpal tunnel release; and Adhesive capsulitis of right shoulder (M75.01).
DOI: 1/19/2015. Patient is a 44-year-old female machine operator who sustained injury while lifting pieces of cardboard into the machine when she felt pain to both sides of her shoulders and neck. Per OMNI, she was diagnosed with cervical and shoulder sprain/strain.
DOI: 6/28/2007. Patient is a 66 year old male ship-packer who developed pain from unloading stack of bread from trailer. Per OMNI, he underwent knee surgery on 5/28/2008, partial knee replacement on 4/12/2010, and elbow surgery on 5/08/2013.
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 OMNI payment screen, last PT session was on 07/28/16.
Per PT daily therapy notes dated 05/26/15, the patient has completed 6 sessions for both hands.
no difficulties and showed no difficulty getting up from a chair. She did not use assistive devices or bracing materials. Full range of motion was recorded in the shoulder joints, elbows, wrists, hands, hips, knees, and ankles. Cervical spine rotation right and left was 80 degrees, with full flexion and extension. The straightaway walk was unremarkable as was the tandem step test, toe lift, heel walk, one-foot stand, and Romberg test. The claimant did not use any assistive devices. Dr. Keown diagnosed the claimant with chronic right shoulder pain, refractory bursitis, or a partial tear of the rotator cuff. She opined the claimant had the ability to sit six to eight hours, walk or stand six to eight hours, occasionally lift 35 to 40 pounds, frequently lift 10 to 15 pounds and would not require assistive devices (Ex. 7F).
S: TM completed ESI X 5 visits. TM reports her shoulder is much better, reports her pain at 2/10 with movement. TM is very appreciative with Medical Clinic and ESI’s service. TM denies any other issues.