quality care you can trust - precision medical group...2019/10/10 · phalen's is negative...
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BEVERLY HILLS 9730 WILSHIRE BLVD, STE. 110
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PP rr ee cc ii ss ii oo nn MM ee dd ii cc aa ll GG rr oo uu pp ,, II nn cc .. Shahriar Bamshad, M.D.,
Medical Director Board Certified Physical Medicine & Rehabilitation - Fellowship Interventional Pain Management
SERVICES •• Board Certified Physicians in Neurology, Physiatry, and Electrodiagnostic Medicine •• Electromyography (EMG) and Nerve Conduction Velocity (NCV) Testing •• Saturday appointments available!
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EMG/NCV and
Neurodiagnostic testing referral
form
Quality Care You Can Trust
For scheduling: 1) Call (855)EMG-NCV1 or 2) Fax directly to 949-955-0220 or 3) E-mail to: [email protected]
Include: 1.Demo, 2.Authorization or RFA and Report if we are submitting Saturday appointments available!
PP rr ee cc ii ss ii oo nn MM ee dd ii cc aa ll GG rr oo uu pp ,, II nn cc ..
Referral Source (Facility Name):___________________________________ Referral Coordinator:_____________________ Date:__________________ FAX and/or EMAIL (To send appt letter and report): _________________________________________________________________
Dr. Name: _______________________ Dr. Phone: _____________________ Patient Name:__________________________ Date of Birth: ____________ Diagnosis(es):____________________________________________________
EMG/NCV and Neurodiagnostic Testing+Consult Report (CPT 99201-99205, 95907-95913, 95886-95887, 99358, 95923, 95937, WC007– Codes and units TBD by testing Dr. at time of exam)
RIGHT LEFT BILATERAL OTHER__________________________________
UPPER EXTREMITIE(S) LOWER EXTREMITIE(S) (Please CIRCLE one) AME • QME • PANEL QME • Work Comp • PI • PPO • Medicare • Cash Follow-up Appointment Date: Comments: M.D. Signature________________________________________ Date ________________ THANK YOU FOR YOUR REFERRALS.
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(Form Rev. July 2015)
(INSERT DOCTOR’S OFFICE NAME) (INSERT ADDRESS)
(INSERT PHONE) (INSERT FAX)
DATE:____________ TO: ONE CALL MEDICAL ATTN: JUSTIN EPSTEIN FAX: 973-257-9512 Mr. Epstein: Please note that from this date forth, all One Call EMG/NCV patient referrals from our facility are requested to be scheduled with our preferred provider, Precision Occupational Medical Group, Inc. (tax id # 20-0535031). Sincerely, (INSERT ONE) Office Manager, Doctor, or Referral Coordinator
John Smith, M.D. Diplomate, American Board of Physical Medicine and Rehabilitation
Diplomate, American Board of Electrodiagnostic Medicine Precision Occupational Medical Group
1805 E. Dyer Road #110 Santa Ana, CA 92705
Phone: (949) 955-0022 Fax: (949) 955-0220 2/9/2010 12:50:20 PM
Patient: XXXX, Regina DOB: 4/17/1966 Physician: Smith ID#: XXXX_REGINA_10020 SEX: Female Ref. Phys: Jones ________________________________________________________________________________ Patient Complaints: Right hand numbness Patient History: The patient is referred by Dr. Jones for an electrodiagnostic evaluation of the right upper extremity. The patient suffered a work related injury while working at an office. The patient reports pain and numbness in the right hand. Physical Exam: GEN: No acute distress, well nourished, well developed HEENT: Normal cephalic, PERRLA, EOMI EXT: No clubbing cyanosis or edema MUSCULOSKELETAL: No asymmetry, mass or tenderness to palpation. Strength is 5/5 in bilateral upper and lower extremities SPINE: There is no tenderness to palpation to the cervical or lumbar paraspinal muscles NEURO: Patient is alert, awake and oriented x 3, muscle tone is normal without clonus. DTR's are symmetrical and normal in bilateral upper and lower extremities. Sensation to light touch is normal Phalen's is negative Tinel's is negative ELECTRODIAGNOSTIC STUDY: Nerve conduction study of the right upper extremity was done today with the surface skin measure at 32 degrees Celcius and above near the site of the recording electrodes. Informed consent was obtained. Needle electromyography was performed with a monopolar disposable needle electrode on selected muscles as shown below. Nerve conductions were performed using standard surface conduction techniques. The patient tolerated the procedure without complications.
SAMPLE EMG/NCV REPORT - NORMAL STUDY
Patient: XXXX, Regina Test Date: 2/9/2010 p. 2 Impression:
There is no electrodiagnostic evidence of a neuropathic or a myopathic process in right upper extremity at this time. Also, no electrodiagnostic evidence of a neuropathy or a plexopathy in the right upper extremity based on the nerve conduction studies. Conventional nerve conduction studies and EMG cannot test the small sensory pain fibers which, when irritated secondary to compression or tendon inflammation etc., could be a source of pain and paresthesias from within the sensory nerves, nerve roots, subcutaneous structures, and/or bony structures, etc.
In compliance with labor code section 4628 and the rules of practice and procedure, specifically 10978 and 10606, the following is supplied. I declare under penalty of perjury, that all opinions in this report are mine. I performed the evaluation and cognitive services at Precision Occupational Medical Group 1805 E. Dyer Road #110, Santa Ana, CA 92705 and that, except as otherwise stated herein, the evaluation was performed and the time spent performing the evaluation was in compliance with the guidelines, if any, established by the Industrial Medical Council or the Administrative director pursuant to paragraph (5) of subdivision (j) of the section 139.2 or section 5307.6 of the California Labor Code. I have complied with the Labor Code section 139.3 and I have offered or received any commissions or inducements for this consultation. The name and contents of the report and billings are true and correct to the best of my knowledge, executed on this date. ______________________________________________________________ John Smith, M.D. Diplomate, American Board of Physical Medicine and Rehabilitation Diplomate, American Board of Electrodiagnostic Medicine
Patient: XXXX, Regina Test Date: 2/9/2010 p. 3 ELECTRODIAGNOSTIC RESULTS:
EMG
Side Muscle Nerve Root Ins
ActFibs Psw Amp Dur Poly Recrt Int
PatComment
Right Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right ExtIndicis Radial (Post
Int) C7-8 Nml Nml Nml Nml Nml 0 Nml Nml
Right ExtCarUln Radial (Post Int)
C7-8 Nml Nml Nml Nml Nml 0 Nml Nml
Right ExtCarRad Radial C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Right BrachioRad Radial C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Upper Cervical Rami Nml Nml Right Mid Cervical Rami Nml Nml Right Lower Cervical Rami Nml Nml Motor Nerves Site NR Onset
(ms) Norm Onset (ms)
O-P Amp (mV)
Norm Amp (mV)
Neg Dur (ms)
Segment Name Delta-O
(ms)
Dist (cm)
Vel (m/s)
Norm Vel
(m/s) Right Median (Abd Poll Brev) Wrist
2.97
<4.0
13.85
>5.0
5.39
Elbow-Wrist
3.75
23
61.33
>50.0
Elbow
6.72
13.51
5.63
Right Ulnar (Abd Dig Min) Wrist
2.81
<4.0
12.30
>5.0
5.94
B Elbow-Wrist
3.59
21
58.50
>50
B Elbow
6.41
11.43
6.56
A Elbow-B Elbow
2.50
14
56.00
>50
A Elbow
8.91
10.78
6.72
Right Radial (Ext Ind Prop) Ext Ind Prop1
1.95
>1.0
4.09
7.34
Ext Ind Prop1-Ext Ind Prop1
0.00
Patient: XXXX, Regina Test Date: 2/9/2010 p. 4 Sensory Nerves Site NR Peak
(ms) Norm Peak (ms)
P-T Amp (µV)
Norm Amp (µV)
Segment Name Delta-P
(ms)
Dist (cm)
Vel (m/s)
Norm Vel
(m/s) Right Median Anti (2nd Digit) Wrist
3.13
<3.7
92.39
>15.0
Wrist-2nd Digit
3.13
>50
Right Ulnar Anti (5th Digit) Wrist
3.19
<3.8
73.65
>15.0
Wrist-5th Digit
3.19
>50.0
Right Median and Ulnar Ortho (Wrist) Median Palm
1.84
<2.3
124.03
>14
Median Palm-Wrist
1.84
Ulnar Palm
1.78
<2.3
43.04
>6
Ulnar Palm-Wrist
1.78
Right Radial Anti (Base 1st Dig) Base 1st Digit
2.00
<2.7
53.17
>13
Base 1st Digit-Base 1st Dig
2.00
FWave/HReflex NR Lat1
(ms) Lat2 (ms)
Delta (ms)
Amp (µV)
Right Median-F (APB)
23.97
0.00
23.97
Right Ulnar-F (ADM)
26.69 0.00
26.69
Right Radial-F (Ext Ind Prop)
23.24 0.00
23.24
Patient: XXXX, Regina Test Date: 2/9/2010 p. 5
20 (µV) 2 (ms)
Right Median Anti Sensory
O
P
T
R Wrist
20 (µV) 2 (ms)
Right Ulnar Anti Sensory
O
P
TR
Wrist
20 (µV) 2 (ms)
Right Median and Ulnar Ortho Sensory
O
P
T
R
Median Palm
O
P
TR
Ulnar Palm
20 (µV) 2 (ms)
Right Radial Anti Sensory
O
P
TR
Base 1st Digit
5000 (µV) 5 (ms)
Right Median Motor
O
P
T
R
Wrist
O
P
T
R
Elbow
5000 (µV) / 200 (µV) 5 (ms)
Right Median-F
5000 (µV) 5 (ms)
Right Ulnar Motor
O
P
T
R
Wrist
O
P
T
R
B Elbow
O
P
T
R
A Elbow
5000 (µV) / 200 (µV) 5 (ms)
Right Ulnar-F
5000 (µV) 5 (ms)
Right Radial Motor
O
P
TR
Ext Ind Prop1
5000 (µV) / 200 (µV) 5 (ms)
Right Radial-F
John Smith, M.D. Diplomate, American Board of Physical Medicine and Rehabilitation
Diplomate, American Board of Electrodiagnostic Medicine Precision Occupational Medical Group, Inc.
1805 E. Dyer Rd., Suite #110 Santa Ana, CA 92705 Tel: (949) 955-0022 Fax: (949) 955-0220
1/29/2009 12:41:04 PM
Patient: XXXX, Delfino DOB: 12/24/1950 Physician: Smith ID#: XXXXXX_DELFIN_08071 SEX: Male Ref. Phys: Jones ________________________________________________________________ Patient Complaints: Neck pain with associated numbness and tingling. Low back pain with radiation into both lower extremities. Patient History: Mr, XXXX is a 57 year-old male with a past medical history significant for cervical strain, history of spondylolisthesis and spinal stenosis, status post lumbar laminectomy and fusion L3-S1. Patient complains of neck pain, numbness and tingling with radiation down both upper extremities (right > left). Patient reports weakness in the legs, left more then the right. Patient also complains of low back pain with radiation down both lower extremities (left > right). Patient denies history of diabetes or thyroid disorder. The patient worked on cement and wood floors which required repetitive bending, stooping, squatting and lifting approximately 60lbs. Patient reports that on the date of injury, he was finishing a cement floor. He was bending over using a 2 x 4 piece of wood to finish the floor when he felt a pull in his lower back and his legs gave out. He fell to the ground on his knees. His current medications include Naprosyn, Vicodin and Captopril. Physical Exam: GENERAL: No acute distress, well nourished and well developed HEENT: Normal cephalic, PERRLA, EOMI EXT: No clubbing, cyanosis or edema MUSCULOSKELETAL: No asymmetry, mass or tenderness to palpation. Strength is 5/5 in bilateral upper extremity. NEURO: Patient is alert, awake and oriented x 3, muscle tone is normal without any clonus. DTR is symmetrical and normal in bilateral upper extremity. Sensation to light touch is decreased in the right L5 and S1 distribution in both legs. Straight leg raise is positive on the right.
SAMPLE EMG/NCV REPORT - ABNORMAL STUDY
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 2 SPINE: There is significant tenderness to palpation in the lower lumbar paravertebrals. Informed consent was obtained. Needle electromyography was performed with a monopolar disposable needle electrode on selected muscles as shown below. Nerve conduction study of was done today with the surface skin measure at 32 degree Celsius and above near the site of the recording electrodes. Nerve conductions were performed using standard surface conduction techniques. The patient tolerated the procedure without complications. Impression: Abnormal Electrodiagnostic Study.
1. There is evidence of an acute L5 and S1 lumbosacral radiculopathy in both lower extremities (left > right). Clinical correlation is recommended.
2. There is evidence of a C6 acute cervical radiculopathy in both upper
extremities. Clinical correlation is recommended.
3. Bilateral ulnar motor CMAP amplitudes were reduced with normal onset latencies. Clinical correlation is recommended. Recommend patient return to complete bilateral ulnar inching study in both arms for further evaluation of entrapment neuropathy at the elbows.
“I declare under penalty of perjury that this statement is true and correct to the best of my knowledge and that I have not violated the Labor Code 139.3.” _____________________________________ John Smith, M.D. Diplomate, American Board of Physical Medicine and Rehabilitation Diplomate, American Board of Electrodiagnostic Medicine
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 3 ELECTRODIAGNOSTIC RESULTS:
EMG
Side Muscle Nerve Root Ins Act
Fibs Psw Amp Dur Poly Recrt Int Pat Comment
Right Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right ExtIndicis Radial (Post Int) C7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right ExtCarUln Radial (Post Int) C7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right ExtCarRad Radial C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Right BrachioRad Radial C5-6 Nml Nml 1+ Nml Nml 0 Nml Nml Right Biceps Musculocut C5-6 Nml Nml 1+ Nml Nml 0 Nml Nml Right Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right C1 Parasp Rami C1 Nml Nml Nml Nml Nml 0 Nml Nml Right C2 Parasp Rami C2 Nml Nml Nml Nml Nml 0 Nml Nml Right C3 Parasp Rami C3 Nml Nml Nml Nml Nml 0 Nml Nml Right C4 Parasp Rami C4 Nml Nml Nml Nml Nml 0 Nml Nml Right C5 Parasp Rami C5 Nml Nml Nml Nml Nml 0 Nml Nml Right C6 Parasp Rami C6 Nml Nml 1+ Nml Nml 0 Nml Nml Right C7 Parasp Rami C7 Nml Nml Nml Nml Nml 0 Nml Nml Right C8 Parasp Rami C8 Nml Nml Nml Nml Nml 0 Nml Nml Right T1 Parasp Rami T1 Nml Nml Nml Nml Nml 0 Nml Nml Left Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left ABD DigMinimi Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left ExtIndicis Radial (Post Int) C7-8 Nml Nml Nml Nml Nml 0 Nml Nml Left ExtCarUln Radial (Post Int) C7-8 Nml Nml Nml Nml Nml 0 Nml Nml Left ExtCarRad Radial C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Left PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Left BrachioRad Radial C5-6 Nml Nml 1+ Nml Nml 0 Nml Nml Left Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Left Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Left Deltoid Axillary C5-6 Nml Nml 1+ Nml Nml 0 Nml Nml Left C1 Parasp Rami C1 Nml Nml Nml Nml Nml 0 Nml Nml Left C2 Parasp Rami C2 Nml Nml Nml Nml Nml 0 Nml Nml Left C3 Parasp Rami C3 Nml Nml Nml Nml Nml 0 Nml Nml Left C4 Parasp Rami C4 Nml Nml Nml Nml Nml 0 Nml Nml Left C5 Parasp Rami C5 Nml Nml Nml Nml Nml 0 Nml Nml Left C6 Parasp Rami C6 Nml Nml 1+ Nml Nml 0 Nml Nml Left C7 Parasp Rami C7 Nml Nml Nml Nml Nml 0 Nml Nml Left C8 Parasp Rami C8 Nml Nml Nml Nml Nml 0 Nml Nml Left T1 Parasp Rami T1 Nml Nml Nml Nml Nml 0 Nml Nml
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 4
Motor Nerves
Site NR Onset (ms)
Norm Onset (ms)
O-P Amp (mV)
Norm Amp (mV)
Neg Dur (ms)
Segment Name Delta-O
(ms)
Dist (cm)
Vel (m/s)
Norm Vel
(m/s) Right Median (Abd Poll Brev) Wrist 3.20 <4.0 6.16 >5.0 3.91 Elbow-Wrist 4.38 27 61.64 >50.0Elbow 7.58 6.08 5.08 Right Ulnar (Abd Dig Min) Wrist 2.66 <4.0 2.89 >5.0 5.23 B Elbow-Wrist 2.97 17 57.24 >50 B Elbow 5.63 2.37 5.63 A Elbow-B Elbow 2.50 12 48.00 >50 A Elbow 8.13 2.31 7.34 Right Radial (Ext Ind Prop) Ext Ind Prop1
1.47 >1.0 9.94 7.03 Ext Ind Prop1-Ext Ind Prop1
0.00
Left Median (Abd Poll Brev) Wrist 3.36 <4.0 6.33 >5.0 5.70 Elbow-Wrist 4.69 28 59.70 >50.0Elbow 8.05 5.90 5.78 Left Ulnar (Abd Dig Min) Wrist 3.67 <4.0 2.84 >5.0 3.67 B Elbow-Wrist 3.59 20.5 57.10 >50 B Elbow 7.27 2.37 2.42 A Elbow-B Elbow 2.50 15 60.00 >50 A Elbow 9.77 1.50 7.66 Left Radial (Ext Ind Prop) Ext Ind Prop1
1.88 >1.0 4.52 6.95 Ext Ind Prop1-Ext Ind Prop1
0.00
Right Tibial (AHB) Ankle 4.22 < 5.8 11.21 >4.0 4.14 Knee-Ankle 7.89 39 49.43 >41.0Knee 12.11 6.92 5.16 Left Tibial (AHB) Ankle 5.16 < 5.8 10.59 >4.0 2.81 Knee-Ankle 8.05 45 55.90 >41.0Knee 13.20 7.17 3.05 Left Peroneal (EDB) Ankle 4.92 <5.5 4.30 >2.5 3.98 B Fib-Ankle 6.33 31 48.97 >40.0B Fib 11.25 3.45 4.45
Side Muscle Nerve Root Ins Act Fibs Psw Amp Dur Poly Recrt Int Pat Comment Right PostTibiailis Tibial L5, S1 Incr Nml 1+ Nml Nml 0 Nml Nml Right MedGastroc Tibial S1-2 Incr Nml 1+ Nml Nml 0 Nml Nml Right AntTibialis Dp Br Peron L4-5 Incr Nml 1+ Nml Nml 0 Nml Nml Right BicepsFemS Sciatic L5-S1 Incr Nml 1+ Nml Nml 0 Nml Nml Right VastusMed Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Right VastusLat Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Right RectFemoris Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Right L1 Parasp Rami L1 Nml Nml Nml Nml Nml 0 Nml Nml Right L2 Parasp Rami L2 Nml Nml Nml Nml Nml 0 Nml Nml Right L3 Parasp Rami L3 Nml Nml Nml Nml Nml 0 Nml Nml Right L4 Parasp Rami L4 Nml Nml Nml Nml Nml 0 Nml Nml Right L5 Parasp Rami L5 Nml Nml 1+ Nml Nml 0 Nml Nml Right S1 Parasp Rami S1 Nml Nml 1+ Nml Nml 0 Nml Nml Left PostTibiailis Tibial L5, S1 Nml Nml 1+ Nml Nml 0 Nml Nml Left MedGastroc Tibial S1-2 Nml Nml 1+ Nml Nml 0 Nml Nml Left AntTibialis Dp Br Peron L4-5 Nml Nml 1+ Nml Nml 0 Nml Nml Left BicepsFemS Sciatic L5-S1 Nml Nml 1+ Nml Nml 0 Nml Nml Left VastusMed Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Left VastusLat Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Left RectFemoris Femoral L2-4 Nml Nml Nml Nml Nml 0 Nml Nml Left L1 Parasp Rami L1 Nml Nml Nml Nml Nml 0 Nml Nml Left L2 Parasp Rami L2 Nml Nml Nml Nml Nml 0 Nml Nml Left L3 Parasp Rami L3 Nml Nml Nml Nml Nml 0 Nml Nml Left L4 Parasp Rami L4 Nml Nml Nml Nml Nml 0 Nml Nml Left L5 Parasp Rami L5 Nml Nml 1+ Nml Nml 0 Nml Nml Left S1 Parasp Rami S1 Nml Nml 1+ Nml Nml 0 Nml Nml
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 5 Right Peroneal (EDB) Ankle 4.45 <5.5 4.87 >2.5 4.14 B Fib-Ankle 6.41 31 48.36 >40.0B Fib 10.86 5.00 4.45
Sensory Nerves
Site NR Peak (ms)
Norm Peak (ms)
P-T Amp (µV)
Norm Amp (µV)
Segment Name Delta-P (ms)
Dist (cm)
Vel (m/s)
Norm Vel
(m/s) Right Median Anti (2nd Digit) Wrist 3.19 <3.7 60.91 >15.0 Wrist-2nd Digit 3.19 >50 Right Ulnar Anti (5th Digit) Wrist 3.41 <3.8 50.00 >15.0 Wrist-5th Digit 3.41 >50.0 Right Median and Ulnar Ortho (Wrist) Median Palm
1.84 <2.3 144.89 >14 Median Palm-Wrist 1.84
Ulnar Palm 2.03 <2.3 24.68 >6 Ulnar Palm-Wrist 2.03 Right Radial Anti (Base 1st Dig) Base 1st Digit
1.72 <2.7 134.47 >13 Base 1st Digit-Base 1st Dig 1.72
Left Median Anti (2nd Digit) Wrist 3.22 <3.7 106.74 >15.0 Wrist-2nd Digit 3.22 >50 Left Ulnar Anti (5th Digit) Wrist 5.44 <3.8 75.26 >15.0 Wrist-5th Digit 5.44 >50.0 Left Median and Ulnar Ortho (Wrist) Median Palm
2.22 <2.3 93.28 >14 Median Palm-Wrist 2.22
Ulnar Palm 1.97 <2.3 21.75 >6 Ulnar Palm-Wrist 1.97 Left Radial Anti (Base 1st Dig) Base 1st Digit
2.34 <2.7 24.87 >13 Base 1st Digit-Base 1st Dig 2.34
Left Dorsal Ulnar Cutaneous (Ulnar Dorsal) Ulnar Dorsal1
1.69 < 2.8 175.84 >17
Right Sural (Lat Mall) 14 cm 3.56 <4.5 30.55 > 6 14 cm-Lat Mall 3.56 Right M Plantar (AHB) Med Mall 2.59 < 3.7 21.47 >10 Right L Plantar (ADM) Med Mall 2.31 < 3.7 23.84 >8 Left Sural (Lat Mall) 14 cm 2.81 <4.5 197.18 > 6 14 cm-Lat Mall 2.81 Left M Plantar (AHB) Med Mall 2.28 < 3.7 25.58 >10 Left L Plantar (ADM) Med Mall 2.25 < 3.7 23.64 >8 Right Saphenous (Ant Med Mall) Med Tibia 2.91 < 4.3 15.75 > 3 Med Tibia-Ant Med Mall 2.91 Left Saphenous (Ant Med Mall) Med Tibia 2.50 < 4.3 12.79 > 3 Med Tibia-Ant Med Mall 2.50
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 6 FWave/HReflex NR Lat1
(ms) Lat2 (ms)
Delta (ms)
Amp (µV)
Right Median-F (APB) 28.69 0.00 28.69
Right Ulnar-F (ADM) 30.33 0.00 30.33
Right Radial-F (Ext Ind Prop) 23.97 0.00 23.97
Left Median-F (APB) 26.82 0.00 26.82
Left Ulnar-F (ADM) 29.42 0.00 29.42
Left Radial-F (Ext Ind Prop) 24.27 0.00 24.27
Right Tibial-F (AHB) 47.52 0.00 47.52
Left Tibial-F (AHB) 48.55 0.00 48.55
Right Peroneal-F (EDB) 44.73 0.00 44.73
Left Peroneal-F (EDB) 45.34 0.00 45.34
Right Tibial H (Gastroc) 29.30 0.00 29.30
Left Tibial H (Gastroc) 33.41 0.00 33.41
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 7
20 (µV) 2 (ms
Right Median Anti Sensory
O
P
T
RWrist
20 (µV) 2 (ms
Right Ulnar Anti Sensory
O P
T
R Wrist
20 (µV) 2 (ms
Right Median and Ulnar Ortho Sens
O
P
T
R
Median Palm
O
P
TR
Ulnar Palm
20 (µV) 2 (ms
Right Radial Anti Sensory
O
P
TR
Base 1st Digit
5000 (µV) 5 (ms
Right Median Motor
O
P
TR
Wrist
O
P
TR
Elbow
5000 (µV) / 200 (µV) 5 (ms
Right Median-F
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 8
5000 (µV) 5 (ms
Right Ulnar Motor
OP
T R
Wrist
O
P
T R
B Elbow
O
P
T R
A Elbow
5000 (µV) / 200 (µV) 5 (ms
Right Ulnar-F
5000 (µV) 5 (ms
Right Radial Motor
P
T
R Ext Ind Prop1
5000 (µV) / 200 (µV) 5 (ms
Right Radial-F
20 (µV) 2 (ms
Left Median Anti Sensory
O
P
T
RWrist
20 (µV) 2 (ms
Left Ulnar Anti Sensory
OP
T
Wrist
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 9
20 (µV) 2 (ms
Left Median and Ulnar Ortho Senso
O
P
T
R
Median Palm
O
P
T
R
Ulnar Palm
20 (µV) 2 (ms
Left Radial Anti Sensory
O
P
TR
Base 1st Digit
10 (µV) 2 (ms
Left Dorsal Ulnar Cutaneous Senso
O
P
5000 (µV) 5 (ms
Left Median Motor
O
P
TR
Wrist
O
P
TR
Elbow
5000 (µV) / 200 (µV) 5 (ms
Left Median-F
2000 (µV) 5 (ms
Left Ulnar Motor
O
P
TR
Wrist
O
P
TR
B Elbow
O
P
T R
A Elbow
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 10
5000 (µV) / 200 (µV) 5 (ms
Left Ulnar-F
5000 (µV) 5 (ms
Left Radial Motor
O
P
TR
Ext Ind Prop1
5000 (µV) / 200 (µV) 5 (ms
Left Radial-F
5000 (µV) 5 (ms
Right Tibial Motor
O
P
T
R
Ankle
O
P
T
R
Knee
5000 (µV) / 200 (µV) 5 (ms
Right Tibial-F
20 (µV) 2 (ms
Right Sural Sensory
O
P
T
R
14 cm
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 11
2000 (µV) / 200 (µV) 10 (m
Right Tibial H
2000 (µV) / 200 (µV) 10 (m
Left Tibial H
20 (µV) 2 (ms
Right M Plantar Sensory
O
P
T
R
Med Mall
20 (µV) 2 (ms
Right L Plantar Sensory
O
P
T
R
Med Mall
5000 (µV) 5 (ms
Left Tibial Motor
O
P
T
R Ankle
O
P
TR
Knee
5000 (µV) / 200 (µV) 5 (ms
Left Tibial-F
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 12
20 (µV) 2 (ms
Left Sural Sensory
O
P
T
R
14 cm
20 (µV) 2 (ms
Left M Plantar Sensory
O
P
T
R
Med Mall
20 (µV) 2 (ms
Left L Plantar Sensory
O
P
T
R
Med Mall
5000 (µV) 5 (ms
Left Peroneal Motor
OP
T R
Ankle
OP
T R
B Fib
5000 (µV) 5 (ms
Right Peroneal Motor
O
P
T R
Ankle
O
P
T R
B Fib
5000 (µV) / 200 (µV) 5 (ms
Right Peroneal-F
Patient: XXXXX, Delfino Test Date: 1/29/2009 p. 13
20 (µV) 2 (ms
Right Saphenous Sensory
O
PT
R
Med Tibia
5000 (µV) / 200 (µV) 5 (ms
Left Peroneal-F
20 (µV) 2 (ms
Left Saphenous Sensory
O
PT
R Med Tibia
Precision Medical Group, Inc. Shockwave Treatment Request Form
Work Comp - MTUS/ACOEM - FDA Diagnoses
PATIENT INFORMATION: Last Name: _____________________________________ First Name: _____________________________________________ Address: _______________________________________ City: ___________________________________ Zip: __________ Sex: M F DOB: ____/____/____ SSN ___________ Phone# (H) ______________________ (W) ___________________ Treating Physician: _________________________________ Practice Name: ____________________________________________ Address: _____________________________________ City: _________________________ Zip: _________ Phone: ____________ Location of Clinic where patient is to be treated: ______________________________________________________________ DIAGNOSIS: Please Circle: R = right, L = left, B = bilateral *Bilateral each area treated on different dates.
R L B 726.11 – Calcifying Tendinitis of the Shoulder R L B 726.10 – Non-Calcifying Tendinitis of the Shoulder R L B 726.2 – Shoulder Impingement R L B 726.32 – Lateral Epicondylitis R L B 726.31 – Medial Epicondylitis R L B 726.50 – Trochanteric Tendinitis
R L B 726.64 – Patellar Tendinitis R L B 726.71 – Achilles Tendinitis R L B 726.71 – Achilles Bursitis R L B 726.73 – Calcaneal Spur R L B 728.71 – Plantar Fasciitis
TREATMENT INFORMATION: Treatment Area: SHOULDER ELBOW HIP KNEE ANKLE HEEL FOOT OTHER ______________________ Has this patient previously received ESWT treatment? YES NO On this area Yes No Date: ____/____/____ Date of Injury: ____/____/____ Claim #: _________________________________ ______________________________ Referring Physician _______________________________________________ _____________________________________________________ Employer’s Name & Phone# Adjuster’s Name Phone# Fax# _______________________________________________ _____________________________________________________ Carrier’s Name & Phone# Carrier’s Address City State Zip AUTHORIZATION CRITERIA ESWT is medically necessary for treatment of patients, and as an alternative to surgery, when the following criteria have been met:
1. Symptoms have persisted for several months. 2. History of at least three unsuccessful conservative treatments. (Listed Below)
THE PATIENT HAS FAILED TO RESPOND TO THE FOLLOWING CONSERVATIVE TREATMENTS:
Immobilization Rest Physical Therapy NSAIDS Splints Strapping Ice Cortisone Shots Orthotics Brace(s) The patient has met the criteria for ESWT treatment and in my medical judgment will benefit with the Sonocur ESWT device. Additionally, _____________________________________________________________________________________________ The patient information listed above was completed by my office staff, or myself, and it is to the best of my knowledge true and factual. Physician Signature: _______________________________________ Physician Name: (Print) _______________________________________ Date: _____________________ SEND RX, DEMOS, PR-2, AND THIS FORM TO FAX: (949) 743-0567 OR EMAIL TO [email protected], or PHONE: 888-98-PAINFREE
(edited 12/07/12)