The patient was subsequently diagnosed with right elbow pain and right hand pain.
MRI od cervical spine dated 9/15/14 (no official report) revealed disc spur complex at C3-4, C4-5, C5-6, and C6-7; moderate central stenosis at C3-4, C4-5, and C5-6; mild central stenosis at C6-7; small disc protrusion in the lateral recesses bilaterally at C7-T1 more prominent on the right; and small central disc protrusion T1-2 without evidence of stenosis.
Per office notes dated 03/23/2016, the patient complained of neck, right shoulder and right upper extremity pain. Physical therapy was helpful for the aching pain in her shoulder, forearm, and wrist. She also has stiffness in the neck. She also had learned biofeedback and progressive muscle …show more content…
Physical examination of the right shoulder exam also revealed tenderness at the anterior joint. She has pain at end of range. She tolerates impingement maneuvers well. Examination of the right upper extremity revealed significant tenderness at the lateral epicondyle, the forearm, and the wrist. Tinel’s is positive bilaterally. Sensation is decreased in the first and second finger. Strength of bilateral shoulder abduction is 5-/5. Right wrist extension is 5-/5. Right grip strength is 5-/5. Impressions are right lateral epicondylitis, carpal tunnel syndrome, cervical radicular symptoms, right shoulder pain with positive impingement sign, cannot rule out intrinsic shoulder pathology. Call was made to ask for any recent office notes; however, none was received prior to sending to peer.
Current request is for 1 GSM High Definition Combo TENS Unit with HAN with Supplies (8 Pairs of Electrodes per Month, 6 AAA Batteries per Month) for Purchase between 5/4/2016 and