DOI: 8/12/2015. Patient is a 38-year old male journeyman carpenter who sustained injuries to his right cheek/lips/jaws and shoulders/upper back when he was struck by a hook that broke from come-along pin. Based on the initial evaluation report dated 03/09/16, the patient complains of jaw pain aggravated by chewing, mouth pain aggravated by biting, face pain worse with chewing and right shoulder pain increased with lifting and overhead work. The patient can perform the following activities but it always caused pain: lift heavy items; grasp items; sleep; and sit for prolonged periods. He was currently taking Ibuprofen 800mg.As of this report, the patient has had 9 sessions of physical medicine. On examination of the right shoulder, there was +3 spasm and tenderness to the rotator cuff muscles, upper …show more content…
Supraspinatus test was positive. Epworth Sleepiness Scale (ESS) score is 13/24. Current medications include postconcussional syndrome, unspecified injury to face, teeth and supporting structures and right rotator cuff sprain. Treatment plan includes acupuncture, multi-interferential stimulator purchase of ProStim 5.0 or equivalent and consultation with a dentist, psychologist and temporomandibular joint specialist. IW was prescribed with ibuprofen. Requested for a complete copy of the office visit report dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA. Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and 5/24/2016. ort dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA. Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and
DOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013. MRI of the lumbar spine performed on 3/24/2016 revealed L5-S1 small right paracentral disc protrusion without significant spinal canal stenosis or neuroforaminal narrowing.
Since the condition required an immediate treatment, Dr. Tehrany recommended and promptly scheduled a shoulder surgery to repair the rotator cuff tear. Later that year, Lt. Scalzo visited Manhattan Orhtopedic Care for a second time, this time for a stiffness and pain in his right shoulder. Since Dr. Tehrany efficiently treated Lt. Scalzo’s left shoulder, there was no doubt that he will be the
A patient is admitted to Nightingale Community Hospital to the surgical unit following an infection to a post-op wound. There were several deficiencies found on the patient’s tracer audit once the patient was admitted to the hospital. One deficiency that was found was that the patient was given medication related to pain and the patient was not reassessed properly per Joint Commission Standards (JC). The deficiency found is within the pain assessment policy of the hospital.
Circumstance: Ayden will maintain contact with medical team monthly. Ms. Smalls (MHP) and Mrs. Wigfall (MHS) discuss Ayden’s recent medical appointments and therapy. Action: MHS report Ayden will start physical therapy at an outside clinic. MHP and MHS discuss Ayden receiving all therapy at the same clinic to reduce several therapy appointments during the week. MHP and MHS review reports given since last week.
His doctor recommended the applicant to have acupuncture and physical therapy. He said that there has not been any discussion of surgeries or injections. He takes Naprosyn three times a week. He claims that he began having radiating pain into his knee since he started treating at Southland Spine. He claims this pain occurs three times per month.
Activities at home and work worsen the pain. Numbness, tingling, and burning sensation are reported with increased pain throughout the week. The patient is requesting medication refills and reports limitations with gripping, grasping, pushing, pulling, and lifting 10 pounds. Activities of daily living are limited due to pain, as
On 11/12/2015, CM wet to the “A” dorm to locate the client. Client was lying in bed and CM requested for the client to come to the social service office. CM along with the client completed Bi-Weekly ILP Review. Client was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting.
DOI: 6/21/2014. The patient is a 52-year-old right-handed female technician who sustained a work-related injury to when metal paper holder sprung out and hit her. She did not lose consciousness but was disoriented and confused. Based on the latest medical report dated 02/27/16, the patient reports that after the injury, she had headaches on the right side of the head and had tinnitus almost right away. She developed blurry vision the next day, nausea disruptions to balance and hearing changes on the right side.
It may also be caused by medial epicondylitis, bony spurs, osteoarthritis, cubitus valgus, tumors, bending the elbow excessively, or subluxation of the nerve on the medial epicondyle. Additionally, cubital tunnel syndrome may occur if the humerus or ulna is
Jean Russell of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Flavia Tocco and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. INTERVIEW SETTING I met Ms. Tocco at the St. John’s physical therapy department. Ms. Tocco was open to providing me information on her current and prior medical history.
Rotator cuff tendinitis may be caused by: • Any occupation or activity that has you keeping the arm in the same position for long periods of time. • Favoring one arm to sleep on each night. • Activities or sports that require the arm to be moved above the head repeatedly, such as throwing a ball, swimming, weight lifting, and tennis. • Any occupation that has the arm held above the head for many hours, and days at a time, such as carpentry or painting. • A lack of coordination using the shoulder and shoulder blade
The report notes a prior shoulder surgery in 2002, on the right shoulder. An X-ray was done of the left shoulder, which did reveal degenerative changes in the acromioclavicular joint, as well as post-surgical changes, and degenerative changes on the right side in the acromioclavicular joint. The applicant was subsequently referred to an orthopedic surgeon, Dr. Peter Simonian. An MRI of the right shoulder was conducted on April 10, 2015, which noted tendinopathy of the supraspinatus and infraspinatus tendons. No tear of the rotator cuff, but a superior labrum anterior to posterior tear extending to the posterior labrum, as well as post-surgical changes.
Rotator cuff injuries are pretty popular and happen to a lot of people. Basically, the two most common types of injury for the rotator cuffs are tears and impingements. Impingements on the shoulder occurs when the soft tissues of your rotator cuff become inflamed and swollen. When this happens, there will be an expansion in size and this will make movement of the shoulders a little bit difficult. This will cause pinching between the shoulder blade and the arm bone when you try to move your shoulders.
Symptoms o Shoulder pain o Pain in the outer side of the elbow o Pain in the inner side of the elbow o Pain in the wrist o Pain at the back of the heel Although in most cases the exact reasoning of tendonitis is unknown, when the cause is known it can be one of two reasons either “overuse” or “overload”. Overuse happens when a particular body motion is repeated too often and overload happens when the level of a certain activity e.g. weightlifting.