Preview

Subacromial Bursitis Case Summary

Satisfactory Essays
Open Document
Open Document
482 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Subacromial Bursitis Case Summary
DOI: 4/20/2016. Patient is a 51-year-old female assembler who sustained a work-related injury to her right hand due to repetitive motion.
Per the PT note dated 06/27/15, the patient has 6/6 sessions for the shoulder.
Per the medical report dated 04/20/16, the patient was prescribed with ibuprofen and provided with cold pack.
MRI of the right shoulder performed on 07/19/16 showed subacromial bursitis and supraspinatus at the myotendinous junction. There is fluid seen in the subacromial bursa compatible with bursitis. There is type 2 acromial slant rendering the patient with moderate anatomical risk for impingement.

Based on the medical report dated 01/25/17, the patient complains of constant pain in the right thumb, described as achiness with increased sharp and shooting and throbbing with forceful activity.
There is persistent left elbow pain over the lateral epicondylar region with percussion tenderness over the ulnar nerve causing tingling into the smaller fingers. Patient also reports continued pain in the right shoulder following the corticosteroid injection. She states the subacromial injection did help her by greater than 50% and increased activity involving range of motion but the pain is starting to come back once again to the point she is
…show more content…
Physical/occupational therapy to the right thumb status post injection at 2 times per week for 3 weeks is requested to maximize benefit. As for the right shoulder, the patient is having significant pain even following the corticosteroid injection. The MRI does show subacromial bursitis of the cervical spine and tendon, fluid in the subacromial bursa, and type 2 acromial slanting rendering the patient moderate epitomical risk for impingement. Patient will be referred for orthopedic surgical consultation for the right shoulder. Right de Quervain's steroid injection was performed under ultrasound guidance on this

You May Also Find These Documents Helpful

  • Satisfactory Essays

    As per OMNI, the patient is status post anterior and posterior C4-5 and C5-6 fusion on 12/30/05. According to the AME report on 1/30/07, allowance to see the treating physician for flare-ups of symptoms or for medication refills are reasonable. As per progress notes on 2/22/16, the patient rates his pain level as 9 without pain medication and as 5 with pain medication. The patient is currently not working.…

    • 319 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    DOI: 9/1/2012. The patient is a 42-year-old female referral coordinator who sustained a work-related injury to her bilateral wrists, right index finger and right elbow due to repetitive typing. As per office notes dated 6/8/16, the patient has not returned to work. She complains of bilateral hand numbness and tingling with grinding and popping upon flexion and extension of the index and middle fingers of the right hand. She complains of bilateral extensor forearm and lateral elbow pain, made worse by grasping and pulling. Objective findings revealed that there is tenderness over the lateral epicondyle. There is positive Cozen’s. There is tenderness over the proximal extensor muscle mass. There are bilateral well-healed surgical scars and bilateral…

    • 306 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    IME Report Summary

    • 300 Words
    • 2 Pages

    Based on the latest medical report dated 05/02/16, the patient complains of bilateral neck pain rated as 6/10. He reports that his right superior shoulder…

    • 300 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    DOI: 9/4/2014. The patient is a 40-year old male carpenter who sustained a work-related injury to his low back and left shoulder after lifting a heavy beam at work. Patient is status post lumbar ESI at L5-S1 per procedure report dated 05/13/15.…

    • 351 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    DOI: 10/1/2014. The patient is a 53-year old male route sales representative who sustained a work-related injury to his bilateral wrists from lifting carts of clothes. As per OMNI entry, he was initially diagnosed with bilateral wrist sprain/strain. MRI of the Left Wrist dated 03/05/2015 showed a small radioulnar joint effusion and subchondral cyst formation. MRI of the Right Wrist dated 03/12/2015 showed subchondral cyst formation. Physical therapy initial report dated 06/11/2015 revealed that the patient has received medications and conservative care to help alleviate the effects of the industrial injury. Past Medical History is significant for high blood pressure. During the evaluation, the patient complains of 9/10 pain throughout the…

    • 328 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    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…

    • 594 Words
    • 3 Pages
    Good Essays
  • Powerful Essays

    Proofreader #1

    • 404 Words
    • 2 Pages

    HISTORY OF PRESENT ILLNESS: The patient is an elderly mail who fell 4 days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He was presented to the emergency room for treatment.…

    • 404 Words
    • 2 Pages
    Powerful Essays
  • Good Essays

    Pauline is a 55-year-old woman, who works at an automobile production factory as an assembly line worker. Pauline began experiencing pain, tingling, numbness, and weakness in her fingers, but in order to continue working to support her family, Pauline ignored these symptoms. Unfortunately, her condition has worsened over time, and she now is experiencing symptoms throughout her fingers, hand, and wrist, making it very difficult to maintain her productivity as an assembly line worker, for it is a very demanding job. This condition has not only affected her work abilities, but also has made daily chores, cooking, taking care of her children, and experiencing sleep difficulty due to pain. Finally, she decided to see a physician, where she was…

    • 182 Words
    • 1 Page
    Good Essays
  • Powerful Essays

    To get the athlete prepared to return to play from a shoulder dislocation after reduction, immobilization, and strength exercised are essential. After immobilization, strengthening is needed to make sure there will be no instability when the athletic/ patient returns to activity.(5) The foundation for all shoulder joint activity is due to a stable scapula. Muscle strengthening exercises to help with scapular control, include: scapular depressions (for the trapezius, and pectoralis minor), rows (for the rhomboids and middle trapezius), pushups with a plus and scapular punches ( for the serratus anterior), and shoulder girdle shrugs. To strengthen the rotator cuff muscles, exercises that incorporate internal rotation (for the subscapularis), external rotation (for the infraspinatus and teres minor), rowing , and scapular depression, should be added to allow the stability to be stronger. (5) These exercises should only be incorporated once the patient has been immobilized for at least 6 weeks. The exercises should gradually be brought in to the rehabilitation program. For first time dislocations, arthroscopic treatments has had the most favorable outcomes.(2) Even though technology has come a long way, the procedures still closely resemble open techniques. Although there are many techniques for shoulder dislocations, once a dislocation has occurred,…

    • 1359 Words
    • 6 Pages
    Powerful Essays
  • Satisfactory Essays

    proofreading

    • 372 Words
    • 2 Pages

    PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. VITAL SIGNS: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.HEENT: Head normal, no lesions. Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directs. INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter. CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowl sounds. Liver, kidneys, and spleen are normal to palpitation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above…

    • 372 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Rotator Cuff Surgery

    • 403 Words
    • 2 Pages

    Tehrany immediately recognized the agonizing shoulder condition that Mr. Weeks had been experiencing. His compassion and sincere care for people suffering from painful orthopedic condition enabled led him to rescheduling his day for a little bit in order to create a free time in-between surgeries to examine and evaluate Mr. Weeks’ shoulder.…

    • 403 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    Daily Progress note

    • 322 Words
    • 2 Pages

    Occupational Therapy Acute Daily Note Date: _________ Diagnosis: _____________________________ Precautions/Weight Bearing Status: ______________________ Pain Level: ____/10 ____________________________________ AM Session Time: ____:_____ to ____:____ Minutes: Group: ________ Individual: _______ PM Session…

    • 322 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Work Related Injury

    • 534 Words
    • 3 Pages

    As per pain management consultation report dated 5/10/16, the patient complains of left hand and finger pain radiating up to the upper extremity, shoulder and cervical spine. She rates her pain as 9. Her left middle finger has severe intractable dysesthesias. There is middle finger digital neuritis. She is able to bend fingers and grasp but only with severe pain consequences. She has severe sensitivity to light touch and cold air, wind, and pressure.…

    • 534 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Everything on Bursitis

    • 612 Words
    • 3 Pages

    Bursitis is a disorder that causes pain in the body's joints. It most commonly affects the shoulder and hip joints. It is caused by an inflammation of the bursa, small fluid-filled bags that act as lubricating surfaces for muscles to move over bones. This inflammation usually results from overactivity of an arm or leg.…

    • 612 Words
    • 3 Pages
    Good Essays
  • Powerful Essays

    Patrick Platt

    • 413 Words
    • 2 Pages

    HISTORY OF PRESENT ILLNESS: The patient is an elderly male, who fell four days prior to admission. He noted immediate pain and swelling in the area just above his left elbow. He presented to the emergency room for treatment.…

    • 413 Words
    • 2 Pages
    Powerful Essays