Active Rehabilitation Case Summary
The patient is a 47-year-old male who reported an injury on 03/24/2010 due to a cumulative trauma
Diagnoses include epicondylitis lateral, radial tunnel syndrome, and carpal tunnel syndrome.
The patient is status post right radial tunnel release.
12/08/15 pre-authorization letter indicates that this is an appeal of the denial for participation in the Active Rehabilitation Program. The request is not for a functional restoration program or PT but for an active rehabilitation program consisting of intensive therapy two hours a day, twice a week. The patient has failed PT and acupuncture. An Active rehabilitation Program will benefit the patient. The goal of this program was to improve his ability to push, pull, reach, lift and increase his right arm strength.
11/16/15 Progress note indicated that the patient has constant pain. He has burning, stabbing pain in the right lateral elbow. He has difficulty in making a full fist. It takes a long time to release with the use of hot water, if he does make a fist. The pain radiates from his shoulder down to his right thumb, index and middle fingers. Pushing, pulling, reaching and turning doorknob aggravate the pain. Pain medications …show more content…
He reported difficulty with gripping, grasping and holding due to pain. He had persistent painful paresthesias of his right arm. 4 A’s assessment for chronic pain management had ben documented. Physical exam was WNL. Treatment plan included UDS, EMG/NCS and medications.
Nerve Conduction Study done on 10/17/15 demonstrated moderate carpal tunnel syndrome on the right side. Compared to his nerve conduction study from 2012, there was some worsening of the conduction.
Treatment to date includes medications, PT, trigger finger injections, acupuncture, radial tunnel release in April 2015 and carpal tunnel release in August
Diagnoses include epicondylitis lateral, radial tunnel syndrome, and carpal tunnel syndrome.
The patient is status post right radial tunnel release.
12/08/15 pre-authorization letter indicates that this is an appeal of the denial for participation in the Active Rehabilitation Program. The request is not for a functional restoration program or PT but for an active rehabilitation program consisting of intensive therapy two hours a day, twice a week. The patient has failed PT and acupuncture. An Active rehabilitation Program will benefit the patient. The goal of this program was to improve his ability to push, pull, reach, lift and increase his right arm strength.
11/16/15 Progress note indicated that the patient has constant pain. He has burning, stabbing pain in the right lateral elbow. He has difficulty in making a full fist. It takes a long time to release with the use of hot water, if he does make a fist. The pain radiates from his shoulder down to his right thumb, index and middle fingers. Pushing, pulling, reaching and turning doorknob aggravate the pain. Pain medications …show more content…
He reported difficulty with gripping, grasping and holding due to pain. He had persistent painful paresthesias of his right arm. 4 A’s assessment for chronic pain management had ben documented. Physical exam was WNL. Treatment plan included UDS, EMG/NCS and medications.
Nerve Conduction Study done on 10/17/15 demonstrated moderate carpal tunnel syndrome on the right side. Compared to his nerve conduction study from 2012, there was some worsening of the conduction.
Treatment to date includes medications, PT, trigger finger injections, acupuncture, radial tunnel release in April 2015 and carpal tunnel release in August