12-03-07 X-Rays at Hospital. The wrist is within normal limits. There is no evidence of fracture.
12-03-07 Doctor’s appointment (evaluation). Distal pulses, radial and ulnar are 2+/4. Gross light touch sensation of fingers, hand, wrist, and forearm are intact with the exception of slight paresthesias in the small and ring finger. Her ulnar nerve stretch test is pos at 40 secs for numbness and tingling in the small and ring finger. Her 1st dorsal webspace, there is some mild atrophy bilaterally. Small finger FDP function is 5+ bilaterally. Finger abduction and adduction strength is 5- on the Rt and 5 on the Lt. Pressure over the carpal tunnel is neg bilaterally. Phalens is neg on the Lt, pos on the Rt for some slight tingling in the index finger at about 40 secs. APB function on the Rt is 5 strength, on the Lt 5+. Palpation of her hand reveals tenderness at the base of the 3rd metacarpal, and tenderness of the scapholunate articulation, both on the volar and dorsal aspects. Grip strength is 5+ with only a slight increase in her pain. Finger flexors are 5+ strength w/o pain. Finger extension is 5+ strength with some pain along the 3rd metacarpal. X-rays obtained today, AP, lateral, and clenched fist view shows a scapholunate widening of 5-6mm. She has a base of the 3rd metacarpal fx that is minimally displaced. Assessment: 1. Rt base of the 3rd metacarpal fx 2. Scapholunate ligament sprain. Referral to a hand surgeon to deal with her scapholunate ligament sprain, since we can not surgically care for that here. As far as the base of the 3rd metacarpal fx is concerned, I think it will continue to heal, and certainly on x-ray shows signs of healing. Her mechanism of injury being a fall does correlate with the base of the 3rd metacarpal fx, as well as the scapholunate ligament sprain. Her X-rays demonstrated 5-6mm widening of the scapholunate without collapse of the capitate. If it was a chronic issue, the capitate would have been collapsed. It was not, which makes me believe that this was an acute process occurring within the last few months. The appearance of her 3rd metacarpal fracture also had the appearance of being within the last few months.
01-23-08 State referred Doctor’s appointment (now primary doctor). (He could only get 1 x-ray because my hand was hurting so bad, they couldn’t get my hand to turn in the positions they needed for the other 2 x-rays, which he doesn’t state in his report). His report: She did not have a lot of swelling in the beginning, but has gradually developed swelling as well. Her pain she describes as along her interosseous membrane from about the mid distal third junction of her forearm down into her hand, also up the volar central aspect of her wrist and hand. She has developed diffuse numbness in the entire hand. She does not feel any worse in the long and index compared to the ring and small. She does have some night pain associated with this. Now she is complaining about pain running up her arm and a focal area of pain around the posterolateral aspect of the arm. She describes this as a “pinched nerve.” She feels like she is developing gradual stiffness in the shoulder as it aggravates her pain to move her shoulder around. She denies any significant neck pain. She noticed that over the first six week period she had gradual increase in wrist pain and then over the next six weeks it came to the point that she could hardly use her hand and this is when she sought her initial treatment. Shoulder evaluation reveals about 70-80 degrees of active abduction and similarly limited for active forward flexion. She cannot externally rotate actively beyond about 0 degrees. She can internally rotate to get her arm against her belly. Passive range causes discomfort. She has focal tenderness over the course of her radial nerve from the posterior humerus and at the lateral intermuscular septum as well as through her radial tunnel. She has negative Tinsel’s over the ulnar nerve and no significant tenderness of the ulnar nerve in the ulnar groove. She has negative Tinel’s at the wrist, both the ulnar and median nerves. She has no evidence of any masses. She has no significant hypesthesias. There is a little redness along her hypothenar eminence, but this may be from her chronic brace wear. She has slight red blotchiness to her skin, but no hyperhydrosis, no anhydrous. She has modest diffuse edema of the hand and a mark from where she was wearing her ring over her ring finger. She has fairly good active flexion and extension of her fingers. She does not want to move her wrist actively at all. Passively I can move her through about 50 degrees of flexion and extension and 20 degrees of radial and ulnar deviation before she gets pain. She has dorsal radiocarpal tenderness most focally over the scapholunate area as well as directly over her triquetrum. She does not have TFCC tenderness. She has some focal tenderness over her interosseous membrane. DRUJ shuck and pisotriquetral shuck are painless. Watson’s test causes her sharp pain, but no evidence of a clunk. X-rays: Three views of the hand are reviewed. I do not see evidence of a fracture. She does not have any evidence of carpal collapse pattern. My gravest concern I that the patient has developed a chronic regional pain disorder. She has some evidence of radial nerve neuritis. I am going to obtain a three-phase bone scan. I will have her evaluated by one of the chronic pain specialists. I will begin her on hand therapy and initiate Neurontin
01-31-08 Bone Scan: Findings-Flow images demonstrate increased blood flow to the right wrist. There is increased blood pool activity. There is increased delayed static activity diffusely throughout the right wrist. There is also increased activity throughout the remainder of the right hand, including the periarticular activity about the metacarpophalangeal and interphalangeal joint spaces. While nonspecific, this is a finding that can be found in patients with complex regional pain syndrome (reflex sympathetic dystrophy). Other differential concerns can include diffuse synovitis from infection either viral or bacterial or a posttraumatic finding. Impression-There is increased blood flow, increased blood pool, and increased delayed static activity identified in the right wrist. There is also increased periarticular activity throughout all the joints in the right hand. This pattern while nonspecific has most commonly described in patients with complex regional pain syndrome (RSD). Also can be seen as a posttraumatic finding on patients with synovitis either infectious or inflammatory. Clinical correlation is warranted. It is possible that this is posttraumatic in etiology and could also represent a posttraumatic synovitis.
02-04-08 Primary Doctor: I evaluated Jean’s three-phase bone scan performed on 01-31-08. This reveals nonspecific increased flow in the right wrist. This is consistent with chronic regional pain disorder and this also was the interpretation of the radiologist.
02-07-08 Pain Management Doctor: She is alert and oriented to person, place and time. She does appear to be quite anxious. She is holding her arm close to her body. Her BP is 170/90, pulse 84, respiration 20. Her right hand comes in glove and when we take the glove off it is swollen, warm to the touch and slightly dusky. She has decreased range of motion on of her fingers but she can extend them all the way. She cannot flex or extend her wrist. She cannot supinate and pronate at the lower forearm. She can move her arm well in flexion and extension at the elbow. She cannot bring her arm above her head. She can bring it up to 90 degrees but when she goes beyond that, she feels a sharp stabbing pain going down her arm. Her right hand is warm compared to the left. She has numbness in all fingers on the right compared to the good pulse. She has good venous engorgement. She is exquisitely tender to deep palpation at the base of her thumb on the medical aspect of her right hand and also very tender in the lower 2/3 of her forearm on the dorsal aspect of it. She has no hypersensitivity to light touch. DTR’s are 2/4.
02-21-08 Pain Management Doctor 1st Stellate Ganglion block, right
02-27-08 Pain Management Doctor 2nd Stellate Ganglion block, right
02-27-08 Primary Doctor: She had block today so she is feeling a little bit tired, but seems to have good relief of her arm pain other than one small focal area of her anterior deltoid, which is painful at this time. She did not have that the last time with her first block. She is still sore in her wrist. She points to three specific areas. One is over the dorsal ulnar aspect of the carpus, not really the TFCC, but more over the triquetrophamate joint. The other is more over the index CMC joint and the last place is over the distal pole of her scaphoid. They are all quite specific. It is a little difficult to examine today. She is improved I her overall composite finger range of motion. She is not significantly hypesthetic. She does have a moderate amount of diffuse edema. Her thumb range has actually improved significantly. She has about 20 degrees of flexion and extension of the wrist, about 20 degrees of ulnar deviation. Radial deviation was not checked. She has about 35-40 degrees of active supination and actually quite a bit better pronation. She has good elbow range. She has switched to Lyrica instead of Neurontin. Released me to go back to work.
03-14-08 Pain Management Doctor 3rd Stellate Ganglion block, right
04-02-08 Pain Management Doctor 4th Stellate Ganglion block, right
04-02-08 Primary Doctor. Jeannie has some anterior cuff tenderness, but more so along her biceps tendon. She guards with any trial of motion. She can actively abduct to about 50 degrees, actively forward flex to about 90 degrees. External rotation is nominal and I did not test internal rotation. Her elbow has good range of motion, nearly full, without significant discomfort. She does have focal tenderness in the wrist in the area previously noted. She also has tenderness over the ulnar aspect of the hand at about the level of the triquetrohamate joint. She ha some diffuse edema of the hand and still has diminished composite flexion of the hand. She does not have significant diffuse hypesthesias as previously.
05-14-08 Primary Doctor. Jeannie still has some shininess to her skin. She has mild swelling. She has some mild blotchy skin tone changes and hypesthesias. It is not nearly as severe as they have been in the past. Ranges of motions are documented on a therapy progress note. She seems to be making slow, but steady progress. Her biggest problem right now is trying to juggle both her job and her rehabilitation. She feels exhausted all of the time. I have been in receipt of a letter from her rehabilitation counselor in regards to this who has suggested maybe backing off on the amount she works. I completely concur. Ultimately she has to make a choice between working and rehabilitating. I do agree that it is good for her to work, but not if she has to overdo it.
05-21-08 Primary Doctor wrote letter to place me on temporary leave of absence from work.
07-14-08 Primary Doctor. Objectively Jeannie has about 25 degrees of wrist extension and maybe 20 degrees of wrist flexion. Her composite range is still limited, although the small finger is nearly full. She still has some shininess to her skin. Hypesthesias are significantly diminished.
08-27-08 Primary Doctor. There is a tan line. There is still shininess to her skin with modest diffuse chronic swelling. There is limited composite flexion. She does not have significant first dorsal compartment tenderness, but does have some volar CMC tenderness of the thumb. Grind test actually reveals reasonable range without crepitation or significant discomfort unless I push her through a wide range. There is dorsal central tenderness. There is some mild, but not nearly as dramatic as previously diffuse tenderness, but not grossly hypesthetic. Distally she had continued to make slow progress, but said she lifted a small wire cage and had quite sharp both radial and ulnar sided pain. She dropped this item. She has had aggravating pain since. She also complains about numbness in the hand, which she describes as in an essentially stocking glove distribution starting about 4 cm proximal to her radiostyloid. She denies that any certain fingers are worse than others, that it is the whole distribution. There is no focal pathology that I think should be addresses as I would be exceedingly concerned that intervening at this point would flare her. I do not think a basal joint injection should be entertained nor do I think nerve conduction studies/EMGs are warranted right now as this creates the same concern. Also her numbness that she describes presently is in a nonanatomic “stocking glove” distribution. I think she could be at one handed duty, but this has presented a bit of a problem before in that by report that is not exactly what is occurring and she has travel tine. For this reason I am going to request an IME on this patient.
10-15-08 IME. Cranial nerves II-XII intact and symmetric to confrontational testing except impaired cranial nerve 8. Light touch sensory examination of the upper extremities revealed sensory deficits over the dorsum of the wrist and tip of the fifth digit. Right upper extremity evaluation revealed shoulder flexion -150 degress, abduction 120 degrees, extension 50 degrees, pain with impingement testing and over the shoulder joint and shoulder girdle. Wrist flexion 25 degrees with extension at 10 degrees, ulnar deviation 7 degrees, radial deviation 15 degrees, supination of the elbow 15 degrees, pronation 40 degrees. Numbness is noted over the ulnar aspect of the hand. She has some localized pain more so localized over specific points as opposed to a generalized pain. No remarkable swelling or erythema was noted over the wrist. Interphalangeal joint restriction was noted with some generalized pain. She was able to grip and perform some alternating movements of the fingers. Light touch did not provoke significant pain. No asymmetry in temperature of the hand was noted.
Assessment – I have been asked to address several different issues based on this examination in reviewing the medical records. 1. Please provide your diagnosis and treatment recommendations aimed at bring Ms. Smith to maximum medical improvement. The most remarkable findings on this examination are localized pain over the wrist and hand. It is also interesting to note that she is so limited in supination and pronation of the forearm as well as limited motion at the right shoulder. Her medical records indicate that she has RSD/CRP and responded well to sympathetic blocks. Today’s examination does show some skin changes and restricted motion at the interphalangeal joints however no change in temperature and no hypersensitivity of the skin was noted. My recommendation would be to obtain an MRI scan with and without contrast of the right wrist to evaluate for bony or joint abnormalities. She focuses on a specific area where there is a small bump that by her report occurred after the fall and has continued to be significantly painful. I would recommend that someone review the previous bone scan ( I was not able to obtain the previous radiologist report of the bone scan and the films are not available for review). To determine if there is other focal areas of increased signal intensity involving the right upper extremity to suggest bony or joint abnormality. To my understanding the triple phase bone scan indicated findings consistent with sympathetic mediated pain. If abnormalities are noted on the MRI or bone scan, then I would recommend specifically addressing those focal areas of abnormalities or pain. If any surgical intervention is being pursed, local block should be performed to reduce the potential for flare up of symptoms. I would also recommend electrodiagnostic studies of the right upper extremity to evaluate for peripheral nerve entrapment. I do realize the concern of possibly flaring up the symptoms, however based on this examination she does not seem to have strong symptoms consistent with chronic regional pain syndrome as much as localized areas that could be responsible for the pain. In addition, she reports that when she has increased her activities her symptoms have flared indicating one of two options. To more aggressively pursue stellate ganglion blocks on at least a weekly basis as she progresses with her exercises and activities with the goal of improving her function and capabilities versus addressing specific localized abnormalities such as within the joint structure that could be the focus in the source of her symptoms. The consideration of increasing her dosage of Lyrica, adding other medications such as amitriptyline may be of benefit. Solely for the treatment of chronic regional pain syndrome/RSD the goals of treatment are to restore motion utilizing methods for pain control to allow this individual to increase her activity. If that is not able to be obtained with the use of regional blocks such as a sympathic sstellate ganglion block, than pursuing local sources that could be responsible for the symptons is necessary. If sympathetic blocks are effective and yet no other etiology has been found to alleviate the symptoms then consideration for placing a cervical spinal seen unit would be appropriate so as to allow this individual to return to a more normal inactive lifestyle. 2. When do you expect Ms. Smith reached MMI, please provide future recommendations. See previous question. Unfortunately this condition may have many variables. I would expect that she may be placed at maximum medical improvement within the next 6 months. Again the treatment and diagnosis in my opinion should be focused on identifying if there are other contributing factors to her symptoms from a physical basis. Updated presurgical psychological evaluation to determine other components that could be contributing to symptomatology. Addressing the specific source responsible for the symptoms be it through possible joint injection, more aggressive self activation of the extremity with return of functional activities which may include work, addressing the symptoms as needed with blocks etc. And to rule out other structural or nerve abnormalities that may cause her concern for the future. 3. What are Ms. Smith’s current work restrictions, if any? Are they temporary or permanent? At this time I would suggest sedentary activities without repetitive use of the hand or wrist until additional diagnostics are performed to evaluate for joint or nerve abnormalities such as writing, keyboard activities, and increased use of the arm. Current restrictions would be considered temporary. 4. When might you expect Ms. Smith to return to unrestricted work? Within 6 months. 5. Can Ms. Smith return to her time of injury occupation? According to the job analysis it would appear to be a light to medium work capacity job depending on the weight of furniture she would have to move. It does however require constant keyboard activity and use of the hand. Currently I would not expect that she would be able to perform those activities. The use at least the previous diagnostic studies would be beneficial in determining if there are local sources that could be responsible for flair of symptoms. If not, then I would suggest to try to increase activities that may require more frequent stellate ganglion blocks to allow her to regain her function. 6. Does Ms. Smith have a permanent impairment from this work injury? Probably though too early to determine. Additional comments. There are a few things that do concern me in this case. One is the amount of restricted motion at the shoulder and elbow. She freely admits that she did not have shoulder pain initially and the symptoms were primarily at the ulnar aspect of the wrist and hand with numbness and localized pain. She was concerned that there were fractures though this has not been verified. She does show some pain behaviors yet not to the degree that her concerns and complaints should be discarded. Hense the need to be sure there are not other abnormalities responsible for the pain that could be alleviated. Therefore EMG/NCS as well as additional diagnostic studies would help in sorting out these issues and if normal, alleviate some of her concerns. Completing these studies prior to her trying to return to work would be recommended.
11-19-08 Primary Doctor. Jeannie still has some taut skin, diffuse edema and tenderness in the same focal area she always does, which is over the long finger CMC joint over the ulnar head, not specifically over the TFCC, and the distal pole of her scaphoid is quite hypersensitive. She has limited composite flexion as well as range. I do think in the sake of completeness nerve conduction studies/EMGs may be beneficial. We have already seen the bone scan, which showed diffuse uptake. There were no focal areas and therefore does not need to be repeated. I do not believe the patient has adequate focal deficit to warrant an MRI. She certainly is not at MMI yet either.
12-08-08 1st Neurologist. Right median TML 2.9 msec, right ulnar 2.4 msec. Right median motor elbow to wrist 58m/sec. Right ulnar below elbow 54 m/sec., above 50m/sec. Right median sensory digit 2 to wrist 64 m/sec. Right ulnar digit 5 to wrist 61 m/sec. Normal right median NCVs. Normal right ulnar NCVs with no evidence of entrapment. (Neurologist said I had put lotion or something on my arm, which was causing his machine not to read correctly – I had not).
01-08-09 Work Restriction by Primary Doctor. Ms. Smith can only use her right arm occasionally 4 mostly as a “helper hand”. She would really struggle & ultimately fail with the above tasks if required to use right hand.
01-28-09 Primary Doctor. Jeannie has some shininess to her skin with some edema. She is not nearly as hypesthetic as she had been in the past. She still has a focal area of tenderness around the distal pole of her scaphoid as well as over the dorsoulnar aspect of her hand. She has limited composite finger range of motion. She is struggling because she is working essentially every day at the furniture store now and finds herself quite fatigued and struggling with performing her rehabilitation.
02-26-09 Primary Doctor with Rehabilitation Counselor. Discussed transfer of care to GP. Would also suggest IME for MRI. (He would not even look at my shoulder, which was the reason for the appointment that I had requested).
05-06-09 MMI. She has obvious redness and sausaging of her right hand, as well as flexion contractures of the fingers, which are not noted on the left side. Temperature is nearly symmetrical at 94 degrees on the right and 93 on the left. Pulses are strong bilaterally, and Allen’s test is negative, though her capillary refill in the right radial artery appears to be slightly decreased relative to the left side. She does have allodynia and decreased grip strength in the right hand relative to the left. In the left upper extremity, she has a normal motor, sensory, and reflex exam, as well as full range of motion. Neck range of motion is also full. In the right upper extremity she has decreased range throughout the right shoulder. Her O’Brien test is positive. She is diffusely tender with range of motion, and is quite tight and guarded, and thus impairment signs are equivocal. Provocative maneuver for posterior labral tear, though, is negative. She does have tightness across the right pectoralis as well, particularly the pectoralis minor. Her motor strength, again, cannot be accurately graded due to pain. Sensation is intact to sharp versus dull, and she appears to be almost hyperesthetic 2-point discrimination is intact throughout the digits of the right hand, and DTRs are normoactive, She has no obvious nail bed changes and has perhaps a slight increase in hair production in the right arm relative to the left. 1. Has Ms. Smith reached MMI for the work injury of September 17,2007? Ms. Smith is at maximum medical improvement. Additional treatment would be warranty however, such treatment should be provided despite the fact that she is, on a more-likely-than-not basis, at MMI. 2. Do you feel the MRI mentioned by IME would be appropriate? No. The MRI would not be appropriate. Ms. Smith has evidence on clinical examination as well as by bone scan, of complex regional pain syndrome (CRPS). While the MRI may potentially show a surgical lesion, she is not a candidate for any surgery of her wrist or shoulder given her ongoing pain complaints and continued issues with CRPS. As a general rule, diagnostic tests should not be ordered unless there is a clear therapeutic benefit of the test. Ms. Smith is not a surgical candidate for any process involving the right arm unless it is a live-saving measure, due to her ongoing CRPS. Thus, additional diagnostic testing is not needed at this time. 3. Are there objective medical findings that support the injury-related diagnosis? Ms. Smith has very strong evidence supporting the diagnosis of CRPS. The AMA Guide to the Evaluation of Permanent Impairment 6th Edition provides fairly rigid criteria for CRPS. Ms. Smith shows evidence of mottled skin, as well as a differential skin temperature and some edema in the hand. She also appears to have fluctuating dry skin, as well as a report of sweating/overly moist skin. Additionally, she does appear to have very smooth skin over the digits, and almost appears sausaging. There additionally is marked joint stiffness into a flexor pattern, and a slight degree of hair growth change, as well as the bone scan. These findings result in a score of 8 points, as noted on Table 15-25 on Page 453 of the Guides. These findings would all be consistent with CRPS. 4. If she has reached MMI, has she sustained a permanent impairment as a result of this injury? Ms. Smith meets the criteria for a Class 3 impairment of the 6th Edition. This can be found on Page 454, Table 15-26. The range would be 26 to 49% right upper extremity impairment. Ms. Smith has a marked degree of functional loss with the right upper extremity. She requires assistance with self-care ADLs, such as cutting her food and the like. This results in a Grade 3 modifier, which would result in zero modification from the default impairment. Her physical examination and her diagnostic/clinical studies also suggest a severe problem, as noted on Page 406, Table 15-6. These are all Grade 3 modifiers. Her average modifier then is 3. This results in a shift from the default impairment of 38% to 49% upper extremity, resulting in a whole person impairment of 29%. Her impairment actually is very similar to the example given on Page 452 through 454.
I went 15 weeks after hurting shoulder at work with no Primary Doctor.
06-10-09 Pain Management Doctor (New Primary Doctor). She is alert and oriented to person, place and time. Blood pressure 180/100, Pulse 84, Respiration 18. Lungs: Clear to auscultation and percussion. Heart: Regular rate and rhythm without murmurs. She has redness and swelling in her right hand, and in her fingers are swollen like sausages. She has some flexion contractures in her fingers. Her temperature feels cool. Pulses are strong bilaternally. Allen’s test was negative, She does have allodynia and decreased grip strength in the right hand compared to the left. In the left upper extremity, she has normal motor, sensory, and reflex exam, as well as full range of motion. Her right shoulder can only be in flexion 90 degrees, and abduction 45 degrees. She is tender in the area of the SIT muscles where they attach. When you touch her forearm, either dorsal or ventral aspect of her hand, it feels like sandpaper. (Almost in tears that I was being written off, I basically begged for his help).
07-01-09 2nd Thearpist
07-22-09 Both Hand & Shoulder Doctor Both want to run tests.
08-18-09 1st Neurologist Normal
08-18-09 MRI on Shoulder (Dye) Shoulder frozen...
08-19-09 MRI on Hand The study is limited due to motion artifact. There is no scaphoid injury. There is a small amount of signal abnormality in the scapholunate which does raise the suspicion for subtle injury to the scapholunte ligament. There is no definite evidence for widing. Careful Clinical correlation is recommended. There is a small defect at the radial attachment of the triangular fibrocartilage complex (adjacent to the radial attachment) raising suspicion for focal perforation. There is no evidence for lunate avascular necrosis. The alignment of the carpal bones is within normal limits. The ulnar styloid is grossly intact. There is no evidence for nerve entrapment.
The foam in casing was pushing against my thumb. I complained to technician and she started wiggling my thumb saying see nothing is touching it. I started crying because she was hurting me and she then wanted to cancel the MRI. I told her she had to get my hand out of case and when she did she saw the hard foam and removed it. We continued with MRI but my hand was spasming the whole time. She kept telling me to hold still but I couldn’t control it.
The foam in casing was pushing against my thumb. I complained to technician and she started wiggling my thumb saying see nothing is touching it. I started crying because she was hurting me and she then wanted to cancel the MRI. I told her she had to get my hand out of case and when she did she saw the hard foam and removed it. We continued with MRI but my hand was spasming the whole time. She kept telling me to hold still but I couldn’t control it.
Was told by attorney that his pockets weren’t deep enough to follow up on landlord negligence that caused me to fall. Because it was such a large company it would take years and they would fight it all the way to the Supreme Court.
8-26-09 Shoulder Doctor Discussed results of MRI and decided to get 2nd Neurologist opinion.
8-27-09 Hand Doctor. I was told I had a small tear above the wrist bone on the right side of my hand but that’s all the MRI showed. There was nothing he could do to help me.
9-30-09 2nd Neurologist. Abnormal due to lesions of several right upper extremity muscles. No evidence of cervical root lesion. The pattern of EMG abnormalities is most suggestive of a brachial plexus lesion, which corresponds well to the clinical limitations of arm motion.
R. Deltoid IA 1+; PPP 2+
R. Flex Carpi Uln IA 2+: Fib 1+; PSW 1+: Pattern reduced
R. Flex Carpi Rad Fib 2+: PSW 1+: Pattern reduced
9-30-09 Shoulder Doctor. Review and scheduled surgery.
Found out my brother had had a very bad seizer and was unconscious for almost 2 weeks. He’s not talking, so we don’t know what he remembers and what he doesn’t.
The state read me report on hand MRI and it states they couldn’t read MRI below thumb but there may be a problem there. Hand Doctor never mentioned this. I needed a doctor to request another MRI.
10-30-09 Preop with Shoulder Doctor and representative from the State. EKG. PROBLEMS. Technician thought I was having a heart attack in the office. I felt fine. Shoulder surgery cancelled.
11-02-09 Heart Doctor. The scheduled stress echocardiogram was cancelled due to poor left ventricular function at rest. There is mild to moderate global hypokinesis on the left ventricle. The ejection fraction estimate is 35-40%. Chamber size is within normal limits. There is no valvular regurgitation.I just completed the preliminary evaluation on Jean Smith to start stress test. She was scheduled for right rotor cuff repair. A preop EKG at PSC showed significant changes, and this was arranged, Her resting picture showed global hypokinesis with an ejection fraction of 45%, and changes consistent with a cardiomyopathy. She tells me a previous evaluation in 2004 showed no injury or infarction, and her workup at that time was normal. She also had an episode of chest pain on Saturday and Sunday. She has no prior knowledge of a myocardial infarction. Give her current findings, it will be prudent to address her new diagnosis of cartiomyopathy, possibly ischemic in origin, before proceeding with shoulder surgery.
11-03-09 Mother-in-law admitted in hospital with pneumonia. Husband leaves a couple of days later for Ohio Columbus
After lots of phone calls I finally find out my case had been referred to another doctor’s office, but they claimed they never received any paperwork.
11-12-09 GP for heart. I was told on phone that the heart doctor was there, but actually he wasn’t. This Doctor really couldn’t help me and said I needed too see heart doctor. She put me on blood pressure medicine.
Tried to make an appointment with heart doctor but he couldn’t see me until the end of December. I called back and the GP referred me to another doctor in their office. I was now to a point I could hardly function.
11-30-09 New GP Got referred to a heart doctor. I was put on beta blocker.
My husband came back home to help me a couple of days before appointment with 2nd heart doctor.
12-09-09 2nd Heart Doctor Tried to run EKG but their equipment wouldn’t work. He said I needed a Heart Cath. right away and referred me to a 3rd Heart Doctor. He said I couldn’t travel but reluctantly finally agreed I could go in a car to Ohio Ohio
12-10-09 Blood test. Decided to have Heart Cath. done here.
12-15-09 Hospital for heart cath. Normal coronary arteries weak heart muscle unknown cause. Viral infection.
12-17-09 Mother-in-law back in hospital – not good. Left for Ohio Ohio Ohio Montana
02-08-10 2nd Heart Doctor follow up after surgery. Released for shoulder surgery.
02-18-10 GP Increased both blood pressure medicine and beta blocker. Got copy of heart doctor’s release, so I could forward it to the State.
03-12-09 Shoulder Doctor & Surgery Center
03-25-10 Shoulder Surgery 3 incisions. (See pictures)
04-02-10 Pain Management Doctor
04-07-10 Shoulder Doctor Follow up. Progress good.
05-12-10 Pain Therapy (Where was this guy 2 years ago?)
05-14-10 Pain Management Doctor
05-19-10 Pain Therapy
05-21-10 GP. Follow up on heart. Everything looking good.
06-18-10 Shoulder Doctor. Follow up. Doing good continue therapy.
08-11-10 Shoulder Doctor Keep up the good work.
08-18-10 2nd Hand Doctor Agreed to evaluate. He has asked for all medical records pertaining to my right hand from the State. I have to get RSD settled down.
09-10-10 3Phase Bone Scan Blood flow and blood pool imaging appear fairly symmetric bilaterally. There is some increased uptake in the left greater than right wrists on delayed imaging, possibly related to degenerative change. There is increased uptake within the left greater than right bilateral wrists on delayed imaging, nonspecific, but suggesting degenerative change. Inflammatory arthropathy or even infection could have a similar appearance; please correlate clinically. There is mild uptake bilaterally in the region of several interphalangeal joints and metacarpal-phalangeal joints, again suggesting degenerative changes. The blood flow and pool imaging is fairly symmetric and appears within normal limits which would make an active infectious or inflammatory process less likely, but again, please correlate clinically. If concern for scapholunate ligament tear persists, this could probably be best evaluated with an MR arthrogram or, if patient cannot undergo MRI, CT arthrogram, as indicated.
09-13-10 2nd Hand Doctor. Says no RSD and will now schedule MRI for right hand.
09-22-10 MRI Right Wrist (With dye). There is mild negative ulnar variance. TFCC appears intact. Scapholunate and lunotriquetral ligaments appears intact. There is mild radiocarpal narrowing and mild joint space narrowing involving several carpometacarpal joint spaces. However, there is no marrow edema. Flexor and extensor tendons appear intact. No evidence of scapholunate, lunotriquetral, or TFCC tear. Mild ulnar variance. Mild degenerative changes in the radiocarpal and carpometacarpak joint spaces.
09-13-10 2nd Hand Doctor. Says no RSD and will now schedule MRI for right hand.
09-22-10 MRI Right Wrist (With dye). There is mild negative ulnar variance. TFCC appears intact. Scapholunate and lunotriquetral ligaments appears intact. There is mild radiocarpal narrowing and mild joint space narrowing involving several carpometacarpal joint spaces. However, there is no marrow edema. Flexor and extensor tendons appear intact. No evidence of scapholunate, lunotriquetral, or TFCC tear. Mild ulnar variance. Mild degenerative changes in the radiocarpal and carpometacarpak joint spaces.
09-27-10 2nd Hand Doctor. Reads above report, and says there is nothing he can do to help me. Then we talked about my index finger, where he said he could do ligament reconstruction. I asked about thumb and was told I can't fix everything. Asked about stinging in my hand and he said I don't know. Asked about my little finger and he said we'll see. He asked about tingling in my hand, and then had assistant run a test on me and said I had carpal tunnel. Sent me out with paperwork for liagment reconstruction for my index finger and carpal tunnel surgery.
10-06-10 Shoulder and Hand doctor. Everything good with shoulder surgery. Doctor said he would probably put me at MMI in 6 more weeks. I can now raise my arm 180 degrees. Still a bit stiff, but I'm doing real good. Discussed surgeries with hand doctor. Asked how I was supposed to do carpal tunnel exercises when I can't bend wrist. He said well I had 3 weeks...(Uh, I've had very little movement in 3 years, how is this going to help). Why is my Thumb being ignored, which is where I have the most pain. He said good question, so another test authorization has been sent to the state. He then started moving my thumb around in a big circle with no warning. I yelled and pulled my hand away. He told me I was over reatcing. ( For 2 days I was back on ice and pain medicene and slept about 20 hours. Shooting pains up my arm again...back to the hard brace).
10-18-10 MRI right thumb in Doctor's office. Said he didn't see anything.
10-20-10 Hand Doctor. Fill ou paperwork for surgery
10-21-10 Surgery for Mallet Finger, Swan Neck and Trigger Finger in right index finger. Also had Carpal Tunnel surgery.
11-1-10 Hand Doctor Post-op
11-10-10 Hand Doctor. Removed stiches
11-17-10 Shoulder Doctor. Wanted to wait a little longer to put me at MMI because of hand surgery.
12-1-10 Hand Doctor. Said I needed surgery to remove wire.
12-2-10 Surgery Removed wire from index finger
12-15-10 Hand Doctor Post-op. Said I didn't have to wear brace anymore and to use compression glove only when needed.
12-22-10 Shoulder Doctor. I'm at MMI
1-5-11 Hand Doctor follow up
Jan thearpy 1-6-11, 1-13-11, 1-20-11 & 1-26-11
1-26-11 Hand Doctor follow up. Doctor upset because I wasn't improving more.
Feb. a month of intense thearpy. All symptons in right finger returned to pre surgery condition. RSD activated again.
3-4-11 Physical Therapy Progress Notes: Active range of motion right wrist flexion 30 degrees, passive 48 degrees, wrist extension with elbow bent 50 degrees, 40 degrees active extension with elbow extended and 62 degrees of passive wrist extension. Active radial deviation 10 degrees, passive 26 degrees, ulnar deviation 12 degrees, passive 18 degrees. Active supination 30 degrees, passive 60 degrees. Active second digit MCP flesion 90 degrees, PIP 70 degrees and DIP 75 degrees. Grip strength, Jamar dynamometer, right 11 pounds, left 50 pounds. She still has significant trouble initiating certain movements. Says she can feel soft tissue blockage.
3-10-11 Functional Capacity Examination (FCE) cancelled due to my blood pressure going up too high. After re-hashing the events for the past 3 1/2 years. Thearpist didn't know what test I was supposed to be taking. State refused to send approval letter, said they didn't need it. They never received records from thearpist.
3-14-11 Hand Doctor follow up. Sent me to heart doctor, who increased medication.
3-25-11 Pain Doctor was to do impairment rating for MMI, but instead wrote letter to state recommendating I be sent to Washington State University, Cleveland Clinic or Mayo Clinic. Physical examination: On physical exam, she is alert and oriented to person, place and time. She is tearful because she is very fustrated. Bllod pressure: 134/80. Pulse 68. Respiration: 18. Weight: 150 lbs. She states her current pain is a 3, the least a 1, and the worst a 7. Today her hand is warm. She has good nail blanching in the right hand compared to the left. It does not appear to be atrophied. She can barely make a fist. She can not extend it beyond 0. She can not evert or invert fingers. She has very limited range of motion in flexion or extension at the wrist. She can not supinate or pronate. It is exquisitely tender along the first and second metacarpal area. It is also tender over the thenar eminence with a burning pain that seems to go up the ulnar from the wrist to the elbow with any pressure. I note no swelling today. It is the same temperature as the left arm without color change.
4-1-11 Pain Doctor called and said state had approved referral.
4-6-11 I was told state was sending paperwork that day to all 3 places and I should hear something the first or second week of May. Hand Doctor follow up.
4-14-11 Heart Doctor. Blood Pressure good Blood test good. To go back in 6 months.
4-27-11 Hand Doctor follow up.
5-11-11 EKG. Nerves are healing.
5-20-11 Functional Capacity Examination (FCE)
5-25-11 Hand doctor
called state said they hadn't heard anything regarding referral.
6-1-11 Hand doctor put me at MMI
7-11-11 Pain Doctor cancelled
9-16-11 Pain Doctor
11-10-11 MMI
.
10-18-10 MRI right thumb in Doctor's office. Said he didn't see anything.
10-20-10 Hand Doctor. Fill ou paperwork for surgery
10-21-10 Surgery for Mallet Finger, Swan Neck and Trigger Finger in right index finger. Also had Carpal Tunnel surgery.
11-1-10 Hand Doctor Post-op
11-10-10 Hand Doctor. Removed stiches
11-17-10 Shoulder Doctor. Wanted to wait a little longer to put me at MMI because of hand surgery.
12-1-10 Hand Doctor. Said I needed surgery to remove wire.
12-2-10 Surgery Removed wire from index finger
12-15-10 Hand Doctor Post-op. Said I didn't have to wear brace anymore and to use compression glove only when needed.
12-22-10 Shoulder Doctor. I'm at MMI
1-5-11 Hand Doctor follow up
Jan thearpy 1-6-11, 1-13-11, 1-20-11 & 1-26-11
1-26-11 Hand Doctor follow up. Doctor upset because I wasn't improving more.
Feb. a month of intense thearpy. All symptons in right finger returned to pre surgery condition. RSD activated again.
3-4-11 Physical Therapy Progress Notes: Active range of motion right wrist flexion 30 degrees, passive 48 degrees, wrist extension with elbow bent 50 degrees, 40 degrees active extension with elbow extended and 62 degrees of passive wrist extension. Active radial deviation 10 degrees, passive 26 degrees, ulnar deviation 12 degrees, passive 18 degrees. Active supination 30 degrees, passive 60 degrees. Active second digit MCP flesion 90 degrees, PIP 70 degrees and DIP 75 degrees. Grip strength, Jamar dynamometer, right 11 pounds, left 50 pounds. She still has significant trouble initiating certain movements. Says she can feel soft tissue blockage.
3-10-11 Functional Capacity Examination (FCE) cancelled due to my blood pressure going up too high. After re-hashing the events for the past 3 1/2 years. Thearpist didn't know what test I was supposed to be taking. State refused to send approval letter, said they didn't need it. They never received records from thearpist.
3-14-11 Hand Doctor follow up. Sent me to heart doctor, who increased medication.
3-25-11 Pain Doctor was to do impairment rating for MMI, but instead wrote letter to state recommendating I be sent to Washington State University, Cleveland Clinic or Mayo Clinic. Physical examination: On physical exam, she is alert and oriented to person, place and time. She is tearful because she is very fustrated. Bllod pressure: 134/80. Pulse 68. Respiration: 18. Weight: 150 lbs. She states her current pain is a 3, the least a 1, and the worst a 7. Today her hand is warm. She has good nail blanching in the right hand compared to the left. It does not appear to be atrophied. She can barely make a fist. She can not extend it beyond 0. She can not evert or invert fingers. She has very limited range of motion in flexion or extension at the wrist. She can not supinate or pronate. It is exquisitely tender along the first and second metacarpal area. It is also tender over the thenar eminence with a burning pain that seems to go up the ulnar from the wrist to the elbow with any pressure. I note no swelling today. It is the same temperature as the left arm without color change.
4-1-11 Pain Doctor called and said state had approved referral.
4-6-11 I was told state was sending paperwork that day to all 3 places and I should hear something the first or second week of May. Hand Doctor follow up.
4-14-11 Heart Doctor. Blood Pressure good Blood test good. To go back in 6 months.
4-27-11 Hand Doctor follow up.
5-11-11 EKG. Nerves are healing.
5-20-11 Functional Capacity Examination (FCE)
5-25-11 Hand doctor
called state said they hadn't heard anything regarding referral.
6-1-11 Hand doctor put me at MMI
7-11-11 Pain Doctor cancelled
9-16-11 Pain Doctor
11-10-11 MMI
.
Long Finger Right Hand Active Range of Motion
Ring Finger Right Hand Active Range of Motion
MP 40-55
IP 40-75
Rad 40-65
Palm 45-60
Wrist
Wrist | 2/7/2008 | 2/12/2008 | 2/15/2008 | 2/21/2008 | 2/27/2008 | 4/14/2008 | 4/23/2008 | 5/6/2008 |
Extensions | 0-10 | 25 | 15 | 15 | 18 | 10 | 20 | 25 |
Flexion | 35 | 30+ | 30-35 | ~30 | 25 | 15 | 20 | 28 |
Radial Dev | 15 | 8 | 15 | 15 | 15 | 10 | 15 | |
Ulnar | 10 | 15 | 5 | -5 | 8 | -7 | 11 | |
Pronation | 85 | 80-85 | 75 | 80-85 | ||||
Supination | 10 | 0+ | 35-45 | 30+ |
Wrist | 6/6/2008 | 7/14/2008 | 9/12/2008 | 10/27/2008 | 10/29/2008 | 11/10/2008 | 11/19/2008 | 12/5/2008 |
Extensions | 30+ | 25 | 35 | 25 | 25+ | 30 | 25 | 20 |
Flexion | 35+ | 25 | 30 | 20 | 20 | 20 | 20 | 20+ |
Radial Dev | 20 | 10 | 10 | |||||
Ulnar | 10 | 10 | 15 | |||||
Pronation | 80+ | 80 | 50 | |||||
Supination | 40 | 30-35 | 30 |
Wrist | 12/24/2008 | 1/2/2009 | 1/5/2009 | 1/16/2009 | 1/22/2009 | 2/13/2009 | 2/20/2009 | 4/2/2009 |
Extensions | 35+ | 20+ | 35 | 20 | 15 | 25 | 30 | 20 |
Flexion | 30 | 30 | 25 | 25 | 25 | 15 | 30 | 25 |
Radial Dev | 10 | 15 | "10-15" | 15 | 10 | 20 | 45 | |
Ulnar | 5 | 0 | 0 | -5 | 5 | 0 | 15 | |
Pronation | 60 | 65 | 80 | 75 | ||||
Supination | 50 | 35 | 25 | 35 |
Physical Therapy diagnosis for shoulder:
Assessment: Pt presents with significant weakness pn and inflammation associated with
not moving her R UE for the past 6 mos. There may be adhesive capsulitis as
shown by a capsular pattern of movement but with pn, mm guarding, significant
RC weakness, RSD, and continued irritation from work activities it is difficult to
fully assess the shoulder. Even with adhesive capsulitis it will benefit the pt to
rest the shoulder in a sling to avoid constantly irritating the shoulder when mm
fatigue especially if she continues to do work that is painful to her tissues. Pt
understands the gentle ROM ex’s and the importance of pn mgmt. Ice was very
helpful in decreasing pn today.
March 2008 R Shoulder Pain/RC weakness/RSD/CRPS. Pt presents with significant
weakness pn and inflammation associated with not moving her UE for past 6 mos.
There may be adhesive capsulitis.
April 2008 RC weakness/pn. Pt had made good progress with ROM until this week as
increased tension of RC and scapular mm limited ROM.
progress with ROM until this week as increased tension of RC and scapular mm
limited ROM.
sling resting her arm but to do more while in the sling instead of using arm
between rest breaks more normally. Rest day in the middle of the week is helping
as pt had 2 days of relief but work is still too much for her shoulder. It has been
emphasized to the pt that she has to rest her arm to be able to move it with
prescribed ex’s to regain the mobility and not overuse it with repetitive motions
that do not help with her strength and ROM but instead just cause pn.
May 2008 RC weakness/pn/RSD. Pt’s progress has been slow due to continued irritation
of the shoulder with work related activities and long work hours that in turn cause
her RSD/CRPS to flare up which limits how much the pt can do to rehab her
shoulder with out further irritating. Her long work days also result in significant
fatigue. Pt’s progress has been slow due to continued irritation of the shoulder
mm with work related activities and long work hours that in turn cause her
RSD/CRPS to flare up which limits how much the pt can do to rehab her shoulder
with out further irritating. Her long work days also result in significant fatigue
for the pt and very little time for her ex’s that she needs to perform specifically for
her shoulder.
June 2008 RC weakness/pn/RSD/Adhesive capsulitis. Pt’s progress has been slowed by
tendinitis of long head of biceps. Pt’s progress continues to be slowed by
tendinitis of long head of biceps. Biceps tendon pn limiting ROM especially
IR/ER and shoulder jt mobility is limited due to capsule and mm tension and mm
guarding. And as a result ER ROM has decreased. PT has been fine w/o using
Game Ready Cooling unit by resting shoulder more to assist with pn mgmt. The
Game Ready did not result in any increase in ROM.
decreased to 2 X wk and that is helping decrease irritation to her arm with less
driving. The pt is not ready to return to work as progress is slow in regaining
normal functional mobility and the use of her UE at work would cause a flare up
of her RSD/CRPS.
July 2008 The same as June still getting burning in arm with activities. Had to return the
cooling unit for my shoulder. PT is making progress decreased R shoulder pn with
ADL’s and gradual increase in endurance and strength as she is tolerating
increased reps and sets with her RC and scapular stabilization ex’s w/o increase in
pn, especially over the biceps tendon. ER ROM is her most limited motion as it
the shoulder jt is in its “frozen” phase of Adhesive Capsulitis. The pt is not ready
to return to work as progress is slow in regaining normal functional mobility and
the use of her UE at work would cause a flare up of her shoulder pn but even
worse her RSD/CRPS Sx in her R wrist/hand would be even worse.
August 2008 Pt continues to make progress with decreased R shoulder pn with ADL’s
and gradual increase in endurance and strength with her RC and scapular
stabilization ex’s, especially over the biceps tendon. Pt had been over doing her
ex’s and causing some increased soreness of the RC but by decreasing ex sessions
for strengthening to 1 X day and every other day as the number of her ex’s has
increased and she is able to do 3 X 10 of each. ER ROM continues to be her most
limited motion as the shoulder jt is in its “frozen” phase of Adhesive Capsulitis.
The pt is not ready to return to work as progress is slow in regaining normal
functional mobility and the use of her UE at work would cause a flare up of her
shoulder pn but even worse her RSD/CRPS Sx in her R wrist/hand would be even
worse.
September 2008 Pt continues to make progress with decreased R shoulder pn with ADL’s
and gradual increase in endurance and strength with her RC and scapular
stabilization ex’s as she is consistent with her Home Ex Program. ER ROM
continues to be her most limited motion as the shoulder jt is still in its “frozen”
phase of Adhesive Capsulitis. The pt is still not ready to return to work as
progress is slow in regaining normal functional mobility and the use of her UE at
work would cause a flare up of her shoulder pn but even worse her RSD/CRPS Sx
in her R wrist/hand would be even worse.
October 2008 Pt’s ROM is less due to mm tension and GH jt tension and pn. Consistent
with Ex’s
November 2008 Pt’s IR/ER PROM are less and painful with a capsular end feel. No
change in AROM except decreased ABD.
December 2008 No change in AROM or PROM but if strength improves pt should
increase AROM.
January 2009 Increase in Abd and IR AROM but no change in PROM due to capsule
tightness and strength is maintained.
February 2009 Pt’s fatigue is due to being very deconditioned as she has not wanted to do
any aerobic ex even though she was encouraged to do so. Pt’s L shoulder
continues to fatigue easily with increase use as pt has not been consistent about
improving RC and scapular mm endurance with her ex’s to prepare her shoulder
for increased use. Increase fatigue also causes results in increased compensation
and mm tension results in increased pn and decreased ROM.
needs to maintain ROM, return to icing her shoulder and resting it when she can
and eating normally to maintain energy.
February 2009 (After hurt at work). Significant loss of pt’s AROM due to pn. L UE
tremors due to overuse.
