Summary:

The patient is a 45-year-old female who sustained an injury on 09/03/13. The patient was typing when she suddenly felta the onset of pain in the right wrist, elbow, and shoulder. The patient's height was 69 inches and weighed 257 pounds.

The patient was diagnosed with complete rotator cuff tear or rupture of the right shoulder, not specified as traumatic, a sprain of the unspecified part of right wrist and hand, adhesive capsulitis of the right shoulder, a tpain inhe right elbow, a sprain of unspecified part of the right wrist and hand, adhesive capsulitis of the right shoulder, a complete rotator cuff tear or rupture of right shoulder, and carpal tunnel syndrome of the right upper limb.

Treatments rendered to date included medications. The patient received a cortisone injections in 01/2014. The patient also received a corticosteroid injection for the biceps on 03/07/17 which …show more content…
There was no definite evidence for a recurrent rotator cuff tear. There were an acromial present and minimal separation involving the acromioclavicular (AC) joint. There was a small amount of fluid and contrast in the subacromial and subdeltoid spaces. There was mild atrophy involving the supra and infraspinatus deltoid and trapezius muscle bellies. There was an irregular signal intensity in the glenoid labrum especially inferiorly and posteriorly suspicious for a labral tear. There was a mild degenerative change involving the glenohumeral joint. Fluoroscopic right shoulder arthrography dated 02/21/17 documented that there was uncomplicated, successful right shoulder injection for MRI arthrogram. X-rays of the right shoulder reviewed on 03/07/17 documented that there was bony architecture with the humeral head centered within the glenoid. There were no fractures or abnormal calcification present. Those were all