Wrist Pain Case Study
DOI: 2/24/2010. Patient is a 46-year-old female home attendant who sustained injury to her right wrist while she was changing her client’s diaper when the client squeezed her right hand. Per OMNI, she was diagnosed with right wrist sprain. She had a right wrist arthroscopy in 2010 performed by Dr. Graziosa.
Based on the occupational therapy re-examination report dated 04/07/16, the patient presents for her 1st visit. She started to have shooting pain on the wrist going to her elbow. She was referred for PT. She reports shooting and throbbing pain in the wrist and elbow, rated as 8/10. Patient’s goal is to be able to use her hand during activities of daily living (ADLs) task.
On examination, there is edema of the hand/wrist. She maintains hands/upper extremity in guarded position. Girth measurement of the upper wrist is 16.0 cm on the right and 15.5 on the left. Upper extremity Quick DASH score is 72.73/100. Patient is …show more content…
independent with bathing, toileting, dressing, grooming and eating, but with difficulty. Moderate muscle guarding and apprehension of movement are noted. Range of motion (ROM) shows extension of 60 degrees, flexion of 40 degrees, radial deviation of 10 degrees and ulnar deviation of 15 degrees. Gross muscle testing shows 2/5 with right wrist flexion, extrension and radial/ulnar deviation. Grip/pinch shows power grip of 7 per square inch (psi), lateral pinch of 2 psi with pain, and tripod pinch and tip pinch/pincer of 1 psi. Repeated grip is 0/0/0.
Current medications include tramadol, Lidocaine and Voltaren cream.
Diagnoses include hand crushing injury, wrist sprain/strain and right radiocarpal joint sprain.
Patient has a history of wrist pain, arthroscopy and subsequent course of hand therapy. She was recommended to have another course of occupational therapy (OT)/hand therapy.
Patient’s problems are right wrist pain with decreased grip/pinch strength which interferes with holding utensil, toothbrush and manipulate fasteners and descried strength which causes difficulty with carrying groceries, cutting food, meal preparation and making bed. Short term goals are to reduce right wrist pain and discomfort, increase strength and grip/pinch, and reduce stiffness. Long term goal is to maximize functional use of the right hand during ADL/leisure/work.
Plan is PT 2 times a week for 6 weeks.
Requested verification from the occupational therapy facility on the number of visits attended to date; however, no callback/report was received prior to the submission of this request to
PA.
Is the request for 12 Occupational Therapy Visits for the Right Wrist between 4/14/2016 and 6/13/2016 medically necessary? C-4 for Preauthorization Request.
NY Medical Treatment Guideline does not address the request.
Based on the occupational therapy re-examination report dated 04/07/16, the patient presents for her 1st visit. She started to have shooting pain on the wrist going to her elbow. She was referred for PT. She reports shooting and throbbing pain in the wrist and elbow, rated as 8/10. Patient’s goal is to be able to use her hand during activities of daily living (ADLs) task.
On examination, there is edema of the hand/wrist. She maintains hands/upper extremity in guarded position. Girth measurement of the upper wrist is 16.0 cm on the right and 15.5 on the left. Upper extremity Quick DASH score is 72.73/100. Patient is …show more content…
independent with bathing, toileting, dressing, grooming and eating, but with difficulty. Moderate muscle guarding and apprehension of movement are noted. Range of motion (ROM) shows extension of 60 degrees, flexion of 40 degrees, radial deviation of 10 degrees and ulnar deviation of 15 degrees. Gross muscle testing shows 2/5 with right wrist flexion, extrension and radial/ulnar deviation. Grip/pinch shows power grip of 7 per square inch (psi), lateral pinch of 2 psi with pain, and tripod pinch and tip pinch/pincer of 1 psi. Repeated grip is 0/0/0.
Current medications include tramadol, Lidocaine and Voltaren cream.
Diagnoses include hand crushing injury, wrist sprain/strain and right radiocarpal joint sprain.
Patient has a history of wrist pain, arthroscopy and subsequent course of hand therapy. She was recommended to have another course of occupational therapy (OT)/hand therapy.
Patient’s problems are right wrist pain with decreased grip/pinch strength which interferes with holding utensil, toothbrush and manipulate fasteners and descried strength which causes difficulty with carrying groceries, cutting food, meal preparation and making bed. Short term goals are to reduce right wrist pain and discomfort, increase strength and grip/pinch, and reduce stiffness. Long term goal is to maximize functional use of the right hand during ADL/leisure/work.
Plan is PT 2 times a week for 6 weeks.
Requested verification from the occupational therapy facility on the number of visits attended to date; however, no callback/report was received prior to the submission of this request to
PA.
Is the request for 12 Occupational Therapy Visits for the Right Wrist between 4/14/2016 and 6/13/2016 medically necessary? C-4 for Preauthorization Request.
NY Medical Treatment Guideline does not address the request.