Right Shoulderer Case Summary
DOI: 06/12/2001. Patient is a 44-year-old female financial aid technician who sustained injury to her right shoulder due to regular job duties. She is diagnosed with right shoulder pain, right shoulder superior labral anterior to posterior tear, right carpal tunnel syndrome, and right dorsal ganglion cyst.
Based on the medical report dated 11/02/2016 by Dr. Tolentino, patient complains of constant right shoulder, arm, wrist, and middle finger pain, rated as 7/10 without medication and 5/10 with medication, aggravated by lifting, and alleviated with medications and physical therapy. Right shoulder pain radiates to the shoulder blade and forearm. She also reports left shoulder and left ankle pain. She had a steroid injection to the right shoulder on 06/07/16 which reduced pain …show more content…
There is tightness in the right hand. Right shoulder range of motion is limited and noted as 90 degrees flexion and 90 degrees abduction. Patient is mildly positive for drop arm and empty can tests and positive for impingement sign on the right shoulder. Strength for the right deltoid is graded as 4/5 and limited by pain and the right interossei graded as 3+/5. Sensation is decreased in the right fingers. Patient has completed 12 sessions of physical therapy with minimal benefit.
She is doing well on her pain medications. She denies any adverse reaction to the pain medications. She does not exhibit aberrant behavior. She is able to do light household chores with the help of pain medications. She is able to do her right Activities of Daily Living with more ease.
She has signed an opioid agreement on 11/02/2016. Opioid risk tool was last completed on 12/31/15, and IW scored 2 which indicates low risk for potential opioid abuse. She has undergone a urine toxicology analysis on 06/27/2016 and has tested positive for O-desmethyltramadol and gabapentin which are consistent with
Based on the medical report dated 11/02/2016 by Dr. Tolentino, patient complains of constant right shoulder, arm, wrist, and middle finger pain, rated as 7/10 without medication and 5/10 with medication, aggravated by lifting, and alleviated with medications and physical therapy. Right shoulder pain radiates to the shoulder blade and forearm. She also reports left shoulder and left ankle pain. She had a steroid injection to the right shoulder on 06/07/16 which reduced pain …show more content…
There is tightness in the right hand. Right shoulder range of motion is limited and noted as 90 degrees flexion and 90 degrees abduction. Patient is mildly positive for drop arm and empty can tests and positive for impingement sign on the right shoulder. Strength for the right deltoid is graded as 4/5 and limited by pain and the right interossei graded as 3+/5. Sensation is decreased in the right fingers. Patient has completed 12 sessions of physical therapy with minimal benefit.
She is doing well on her pain medications. She denies any adverse reaction to the pain medications. She does not exhibit aberrant behavior. She is able to do light household chores with the help of pain medications. She is able to do her right Activities of Daily Living with more ease.
She has signed an opioid agreement on 11/02/2016. Opioid risk tool was last completed on 12/31/15, and IW scored 2 which indicates low risk for potential opioid abuse. She has undergone a urine toxicology analysis on 06/27/2016 and has tested positive for O-desmethyltramadol and gabapentin which are consistent with