Hypnotherapy Case Studies
DOI: 1/8/2013. The patient is a 47 -year-old right hand dominant female front packaging employee who sustained cumulative trauma secondary to regular and customary job duties. As per OMNI, the patient was diagnosed with left shoulder impingement syndrome status post arthroscopy on 3/4/15. Official operative report is not available at the time of review. According to the supplemental AME report on 2/23/16, the patient should retain access to a surgical award to allow for the possibility of left shoulder arthroscopy/ manipulation under anesthesia/ arthroscopic lysis of adhesions in the future, should her symptoms progress to the point that she expresses a strong desire to undergo surgery. The patient should also retain access to follow up visits
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with a physician with continued provision of appropriate pharmacological agents. In the setting of acute symptom flare-ups, re-instatement of brief courses of traditional physical therapy/ chiropractic treatment/ acupuncture/ massage therapy would be beneficial. The examiner notes that corticosteroid injections to the bilateral subacromial spaces would be appropriate as well. As primary treating physician’s initial report on 3/3/16, the patient complains of frequent aching and sharp bilateral shoulder pain. She rates the pain as a 9/10 at rest and with activity. Pain increases with lying down, lifting, carrying, pushing, and driving.
Pain decreases with rest and lying down. She also complains of numbness, swelling and insomnia. She was placed in physical therapy and she has attended six sessions. She was taken off work on 5/30/14. She has allergy to cortisone. Her past surgical history is significant for left shoulder surgery on 3/4/15. Examination of left shoulder reveals three arthroscopic scars status-post distal clavicle surgery. There is tenderness to palpation of the greater tuberosity. There is also tenderness to palpation anteriorly and over the distal clavicle. She has limited range of motion of the left shoulder including 50 degrees of extension, 135 degrees of flexion, 70 degrees of internal rotation, 60 degrees of external rotation, 110 degrees of abduction and 50 degrees of adduction. There is some weakness of the subscapularis on the left. The patient has a positive Hawkin’s impingement maneuver. As per progress report dated 6/10/16, then patient returns for evaluation of the left shoulder. She has been authorized for evaluation of the left shoulder. Her right shoulder continues to be painful as well. The patient describes her pain as a constant aching pain that is rated at
8-9. She has increased discomfort with any movement. The patient reports weakness of the shoulders. Physical examination of the right shoulder revealed that there is 150 degrees of forward flexion, 140 degrees of abduction and 70 degrees of internal and external rotation. Left shoulder examination revealed that there are arthroscopic portals and axillary incision. Range of motion is 150 degrees of forward flexion, 145 degrees of abduction and 70 degrees of internal and external rotation. She is markedly tender over the distal clavicle. Diagnoses include incomplete tear of the rotator cuff, right shoulder; impingement syndrome, left shoulder; and status-post surgery, left shoulder.
with a physician with continued provision of appropriate pharmacological agents. In the setting of acute symptom flare-ups, re-instatement of brief courses of traditional physical therapy/ chiropractic treatment/ acupuncture/ massage therapy would be beneficial. The examiner notes that corticosteroid injections to the bilateral subacromial spaces would be appropriate as well. As primary treating physician’s initial report on 3/3/16, the patient complains of frequent aching and sharp bilateral shoulder pain. She rates the pain as a 9/10 at rest and with activity. Pain increases with lying down, lifting, carrying, pushing, and driving.
Pain decreases with rest and lying down. She also complains of numbness, swelling and insomnia. She was placed in physical therapy and she has attended six sessions. She was taken off work on 5/30/14. She has allergy to cortisone. Her past surgical history is significant for left shoulder surgery on 3/4/15. Examination of left shoulder reveals three arthroscopic scars status-post distal clavicle surgery. There is tenderness to palpation of the greater tuberosity. There is also tenderness to palpation anteriorly and over the distal clavicle. She has limited range of motion of the left shoulder including 50 degrees of extension, 135 degrees of flexion, 70 degrees of internal rotation, 60 degrees of external rotation, 110 degrees of abduction and 50 degrees of adduction. There is some weakness of the subscapularis on the left. The patient has a positive Hawkin’s impingement maneuver. As per progress report dated 6/10/16, then patient returns for evaluation of the left shoulder. She has been authorized for evaluation of the left shoulder. Her right shoulder continues to be painful as well. The patient describes her pain as a constant aching pain that is rated at
8-9. She has increased discomfort with any movement. The patient reports weakness of the shoulders. Physical examination of the right shoulder revealed that there is 150 degrees of forward flexion, 140 degrees of abduction and 70 degrees of internal and external rotation. Left shoulder examination revealed that there are arthroscopic portals and axillary incision. Range of motion is 150 degrees of forward flexion, 145 degrees of abduction and 70 degrees of internal and external rotation. She is markedly tender over the distal clavicle. Diagnoses include incomplete tear of the rotator cuff, right shoulder; impingement syndrome, left shoulder; and status-post surgery, left shoulder.