Case name DOB: 03/22/YYYY

Narrative Summary

On May 3, YYYY, Case name, a 34-year-old male was a restrained operator of a motor vehicle
that was hit when another vehicle exiting driveway, failed to yield the right of way and pulled out in front
of Mr. XXXX’s vehicle. Upon impact, his left shoulder struck the interior of his vehicle.

On the same day, Mr. XXXX went to the Urgent Care for complaints of headache and left
shoulder pain. Upon examination, Mr. XXXX was recommended muscle relaxers. He was provided a
sling.

On June 7, YYYY, Mr. XXXX presented to Chad Mikesell, PT at FMCCP-McKinley Health

Center for evaluation and to begin a course of physical therapy. He complained of left shoulder pain and
headache after a motor vehicle accident on 05/03/YY. He was driving and was hit in the rear passenger
side by a car pulling out of a lot. He took impact on his left shoulder on the driver door. He had some
onset of shoulder weakness right away. He went to Urgent care later that day and got a sling, muscle
relaxers. He had neck tightness. He saw his doctor and got an MRI of his shoulder. He wore the sling off
and on; he felt stiff when wearing the sling, but weakness and looseness when out of the sling. He had
pain at the superior aspect of his left shoulder and radiating towards his neck. Though his pain intensity
had decreased, he still had a constant dull aching, sharp pain reproduced by movement-pushing, pulling.
He was not able to sleep on left side. He had some occipital and some frontal, daily headache lasting
15min to 1 hour. He rated his pain as 4 to 6 on a pain scale of 10. Following a series of tests and complete
physical examination, Mr. XXXX was diagnosed with left shoulder pain and partial subscapularis tear.
He was recommended to undergo physical therapy 1to 2 times a week for 2 months. His treatment plan
included manual therapy, therapeutic exercises, therapeutic activities, neuromuscular reeducation and
home exercise program.

On August 4, YYYY, Mr. XXXX presented to Mohan S. Dhariwal, DO at MCW-Westbrook

Health Center for complaints of left shoulder pain and headache. He tripped and fell three weeks prior to
the presentation. A review of his systems was positive for left shoulder pain and left foot pain. He was
unable to raise his left shoulder above 180 without pain. Upon examination, Mr. XXXX was diagnosed
with left shoulder pain and left foot trauma. He was prescribed Meloxicam. He was recommended an X-
ray of his left foot. He was referred to Orthopaedics.

On August 27, YYYY, Mr. XXXX presented to William G. Raasch, MD at FMCCP-McKinley

Health Center for left shoulder discomfort. He was undergoing physical therapy. Despite physical
therapy, he continued to experience some lateral and posterior shoulder discomfort. He had good rotator
cuff strength but slight lateral discomfort resisted external rotation. He had a positive Jobe’s test. Hawkins
sign was minimal. O’Briens test did trigger some deeper shoulder discomfort more superior and
posteriorly. O’Driscoll shear test also triggered some mild discomfort. He had a 2+ laxity symmetric with
the opposite side. He had a poor centering of the humeral head, without ranging the shoulder, Scapular
thoracic kinematics was good. Upon examination, he was diagnosed with possible associated labral
pathology with the cuff symptoms. He was recommended an MRI of his left shoulder.

On September 9, YYYY, Mr. XXXX presented to the emergency room for complaints of
numbness. He had intermittent numbness tingling to the right side of his face for the past 3 days. He had
one episode per day, lasting for 45 minutes at a time. The symptoms came on randomly and were not
affected by chewing, talking, or touching the face. He described his symptoms as numbness starting at his
Case name DOB: 03/22/YYYY

upper lip extending superiorly along the right side of his nose and laterally under the right eye. The
symptoms did not involve the eye or the tongue. He did not endorse sinus congestion for the past few
days. He noted sensation of pressure over bilateral maxillary sinuses. A review of his systems was
positive for tingling and sensory change.

On September 14, YYYY, Mr. XXXX presented to Mohan S. Dhariwal, DO at MCW-Westbrook

Health Center for numbness. Upon examination, Mr. XXXX was diagnosed with chronic pansinusitis,
numbness and tingling of right face and Trigeminal nerve irritation. He was recommended CT of sinus.
He was referred to Otolaryngology. Possible etiologies for the nerve pain was discussed.

On September 17, YYYY, Mr. XXXX presented to William G. Raasch, MD at McKinley Health
Center for review of his MRI of left shoulder. The MRI revealed posterior labral fraying with cuff fraying
and posterior glenoid wear. Findings as well as surgical and non-surgical options were discussed. It was
decided that he would consider his options. He had elected to begin with physical therapy. Mr. XXXX
was advised to follow-up in 6 weeks for a recheck.

On September 25, YYYY, Mr. XXXX presented to Alexander Romashko, MD at Westbrook

Health Center-CP for sinus issues. He had a headache since a motor vehicle accident in May YYYY. He
did not know if he hit his head. Over the past month he had progressively worsening sinus issues. He had
3 episodes of facial numbness on the right and one episode of tingling on the left which eventually led to
him being evaluated in the ER. He was having a headache which got intense and was felt over his
forehead/frontal region as well as the back of his head. He had facial pain/pressure like there was a "fist in
it." He had ear popping/pressure and a lot of nasal congestion. He was not on antibiotics. He had a history
of allergies as a child but only mild allergies as an adult. He only used allergy medication when needed.
Otoscopy revealed generalized mild tympanic membrane retraction/negative middle ear pressure
bilaterally; septum was leftwards deviated. Nasal mucosa was hypertrophic and the turbinates were
essentially obstructive on the right with what appears to be polypoid tissue inferiorly in the nasal cavity,
as well as very large inferior turbinate on the left. The CT sinus dated 09/18/YYYY was reviewed. Upon
examination, Mr. XXXX was diagnosed with chronic bilateral sinusitis; chronic persistent headache; right
nasal polyposis; nasal obstruction with leftwards nasal septal deviation, bilateral inferior turbinate
hypertrophy; allergy/allergic rhinitis - subjectively mild per patient. He was recommended an intensive
medical therapy including Ceftin and Prednisone. He was recommended to call the clinic for post CT
sinus if his symptoms did not significantly improve after 3 weeks. He was advised to follow-up on as-
needed basis, if he was doing well.

Mr. XXXX returned to Chad Mikesell, PT at McKinley Health Center-CP for physical therapy as
and when directed from June 12, YYYY through October 22, YYYY. As on October 22, YYYY, Mr.
XXXX reported that he was not very active that week due to being busy. He reported that he would see
Dr. Raasch next week and was planning to go the structural route and likely pursue a shoulder
arthroscopy. He felt that he was still improving, but was unsure about his full recovery if the structure in
his shoulder was not quite right. His Quick dash score was 15.91% (was 34.09% at start of care 6/7/18).
Patient had 3 more visits per calendar year per insurance. It was decided that if he was to have surgery,
the three pending visits would be better utilized following surgery.

On November 9, YYYY, Mr. XXXX presented to Mohan S. Dhariwal, DO at Westbrook Health

Center-CP for pre-operative evaluation. He complained of left shoulder pain and failing conservative
treatment. A review of systems was positive for little depression, tinnitus and right-sided decreased
Case name DOB: 03/22/YYYY

hearing. His cardiovascular examination revealed 2/6 early systolic, medium pitched, harsh murmur in
aortic area, at base and at left lower sternal border. It was opined that based on current medical
conditions, Mr. XXXX did not meet criteria for postoperative medicine consultation.