Medical Case Presentation

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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
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