3rd Qtr Physician 2016 Radiology Case Study #3- Ortho
51 y/o F CIGNA SI-PPO/OAP
Provider Specialty: Family Practice
Request Initiated: 05/03/2016
CPT: 73221 MRI Upper Extremity, any joint; without contrast material(s)
ICD10: M25.511 Pain in right shoulder
Nurse Reviewer Note:
Per Web/ACDS note/ FP req. MRI Rt Shoulder wo for 51 yoF w/ Right shoulder pain x 2-3 months.
Reason : for eval.
FOV: 02/17/16 LOV: 05/03/16
PE: Active abduction to about 120?. She has pain beyond 90?. Internal rotation to about L5 compared to T12 on the left. Passive external rotation to about 40-50?. Impingement signs are positive. She continues to have normal strength with resistance to the rotator cuff with discomfort mostly in resistance of the supraspinatus.
PMH : Hx of Cancer or Surgery - not provided. No injury.
Prior imaging: X-ray of her right shoulder-shows no fractures or bony changes. No calcifications
TX She has treated with both her primary care physician and a specialist and started PT at the initial visit. She has not improved with PT and 2 injections over the last 3 months with office visits noted on 4/1/2016 and 5/3/2016.
Reviewed Web/ACDS note.
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