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STEBBINS JR,RICHARD L Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
1413-746-9700 2
3/5/2013 3:10 PM Shields Health Care
BAYSTATE
MRI & IMAGING CENTER
Baystate MRI - Springfield
MR # 70-13-95-43 FINAL Diagnostic Imaging Report
Patient: Stebbins, Richard Jr Sent To: Karas, Sumner E MD
300 Birnie Ave/Ste 201
Home:413-949-1925 Att: Peter Michaud PA
MRN: 4238158
DOB: Oct 8 1978 (Age 34 at exam) Springfield MA 01107
Referring Physician: Karas, Sumner E MD
Accession Exam date Exam time Procedure
4238158.2 Mar 5 2013 07:40 am
MRI - Shoulder (C-) CPT 73221 - Right
Room Description: Bay Siem Espr 1.5
MRI Technique:
Ax PD FS Blade, Cor T2 Blade, Cor PD FS Blade, Sag PD FS Blade, Sag T1
Report
Clinical History: Pain, question rotator cuff tear.
Technique: MRI of the right shoulder was performed without intravenous
contrast.
Comparison: Right shoulder MR arthrogram dated 2/3/2010 from the MRI
Center of Springfield.
Findings:
Rotator cuff: There is a full-thickness retracted tear of the anterior fibers of the supraspinatus, with retraction by approximately 2.6cm.
Just posterior to thus, there is intrasubstance tearing of the distal fibers of the supraspinatus. The infraspinatus, teres minor and subscapularis tendons are intact. There is normal muscle bulk.
Glenoid labrum and biceps tendon: There is no displaced labral tear.
The previously noted posterior labral tear and para labral cyst are no longer visualized. The biceps tendon is in the groove.
AC joint: There is postoperative change of the acromioclavicular joint consistent with interval distal clavicular resection and subacromial decompression.
INFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/GLIENT. NOT
FOR DISCLOSURE.
1 of 2 - Richard Jr Stebbins - Accession: 4238158.2 - Exam Date: Mar 5 2013
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STEBBINS JR,RICHARD L
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Articular cartilage: The articular cartilage is of normal thickness. A
partial thickness cartilage fissure is seen in the posterior superior
glenoid.
Bone: There are degenerative cysts in the posterior superior humeral
head.
Impression:
1. New full-thickness tear of the anterior fibers of the supraspinatus
with intrasubstance tearing seen in the distal supraspinatus just
posterior to this.
2. Non-visualization of the previously noted posterior labral tear with
para labral cyst.
3. Partial thickness cartilage fissure in the posterior superior
glenoid.
Electronically signed by Amy Oliveira MD on Mar 5 2013 at 2:39 p.m
INFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE.
2 of 2 - Richard Jr Stebbins - Accession: 4238158.2 - Exam Date: Mar 5 2013
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STEBBINS JR,RICHARD L
Page 3 of 13
Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
. Baystate min Health
Baystate Medical Center
759 Chestnut Street
Springfield, MA 01199-
Patient Name: STEBBINS, RICHARD
MRN: 339334
Account Number: 583544400
Attending Physician: Adler MD, Louis M
Patient Location: NE Ortho Bernle
Date of Birth and Sex: 10/8/1978 Male
Admit Date and Time: 3/4/2013 07:02 EST
Neurodiagnostic
Document Type: Electromyogram/Nerve Conduction Study
Event Date: 3/4/2013 08:24 EST
Result Status: Auth (Verified)
Signed By: Baquis MD,George D (3/4/2013 21:30 EST)
EMG Nerve Conduction Study
BAYSTATE MEDICAL CENTER
Neurodiagnostics and Sleep Center
(413) 794-5688
ELECTROMYOGRAPHY REPORT
Referring Provider: Louis M . Adler, M.D.
EMG Physician: George D. Baquis, M.D.
EMG Technologist: G B
Limb Temperature: Warmed throughout testing with hot pack and Accuwarm Heating System to greater than 34° C
Date of Service: 03/04/2013
Order ID: 1345928011
IMPRESSION: The study is abnormal because of a mild right ulnar sensory neuropathy. This is characterized by mild ulnar sensory axonal loss.
The abnormality is of indeterminant age. There is no associated denervation of
ulnar nerve or lower brachial plexus innervated muscles. There is no evidence of focal entrapment of the ulnar nerve at the wrist or elbow by nerve conduction testing. There are no associated abnormalities suggestive of a lower brachial plexopathy.
There is no evidence of a focal median neuropathy at the right wrist or a distal polyneuropathy affecting his right upper extremity.
CLINICAL PRESENTATION: The patient is a 34 year-old male who is 6' 0" tall and weighs 200 pounds. He was hit by a car and injured his right upper inner arm and outer arm. He has left wrist pain, right wrist pain, right outer elbow pain, and right upper inner arm discomfort. Pressure over his right mid upper arm evokes
ulnar tingling of his entire arm. Examination shows negative Tinel sign over the right median nerve at the wrist and nerve at the elbow, normal hand strength, and evocation of tingling to mild pressure over the right upper medial biceps. Absence of palpable arm mass.
The study is performed for evaluation of a right ulnar neuropathy or lower brachial plexopathy.
FORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE.
Printed on 11/13/2013 12:00 PM
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STEBBINS JR,RICHARD L
Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
Baystate Medical Center
759 Chestnut Street
Springfield, MA 01199-
Patient Name: STEBBINS, RICHARD
MRN: 339334
Account Number: 583544400
Discharge Date:
Patient Type: One Time OP
Neurodiagnostic
Comparison normal nerve conduction values, nerve conduction tables and waveforms, and muscle table are comparison included with the complete printed report. Selected left-sided testing was performed for the purpose of to the right side.
SUMMARY: The right median (APB) and ulnar (ADM) motor distal latencies, distal amplitudes and forearm nerve conduction velocities are normal, The right ulnar nerve conduction velocity is normal to stimulation above the elbow and at the axilla. In particular, there is no abnormal nerve conduction slowing along the right ulnar nerve across elbow or upper arm segments. There is no abnormal conduction block. The right ulnar (FDI) across wrist nerve conduction velocity is normal and there is no abnormal conduction block.
The right median(APB) and ulnar(ADM) minimum F response latencies are normal.
The right ulnar antidromic sensory peak distal latency is normal, the distal amplitude is slightly reduced (11 uV) and nerve conduction velocity is normal to stimulation below and above the elbow. The comparison left ulnar antidromic sensory peak distal latency is normal and the distal amplitude is normal (17 uV). The right dorsal ulnar cutaneous sensory amplitude and peak distal latency are normal. The left dorsal ulnar cutaneous sensory amplitude and peak distal latency are also normal (obtained for the purpose of comparison; left side slightly lower than the right side, but the difference of less than 50% is within the range of acceptable interside comparison asymmetry). The right dorsal radial cutaneous sensory amplitude and peak distal latency are normal.
The right median and ulnar peak distal latencies are normal to palmar technique mixed nerve stimulation.
Concentric needle EMG testing was performed of proximal and distal right hand and arm muscles including those innervated by the median, ulnar and radial nerves, lower cervical nerve roots and the lower trunk of the brachial plexus. Insertional activity is normal, There is no abnormal spontaneous activity. Motor unit potential recruitment and activation patterns are normal. Motor unit potential configurations are normal. There is no evidence of denervation or reinnervation. In particular, there is no evidence of denervation of muscles innervated by the lower trunk of the brachial plexus or ulnar nerve.
Dictated by; George D Baquis M.D.
Signing Clinician: George D Baquis M.D.
Dictated: 03/04/2013 08:24:30
Transcribed: 03/04/2013 18:09:39
Transcribed by: NAB
DocID: 2171089
CC: Louis Adler M.D.
New England Orthopedics Surgeons
INFORMATIOR IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED B Y THE PATIENT/CLIENT. NOT
FOR DISCLOSURE.
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STEBBINS JR,RICHARD L Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
Page 5 of 13
Baystate Medical Center
769 Chestnut Street
Springfield, MA 01199-
Patient Name: STEBBINS, RICHARD
MRN: 339334
Account Number: 583544400
Discharge Date:
Patient Type: One Time OF
Neurodiagnostic
300 Birnie Avenue Suite 201
Springfield, MA, 01107
Mark S. Skalski M.D.
Riverbend Medical Group
305 Bicentennial Hwy
Springfield, MA, 01118
INFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE
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STEBBINS JR,RICHARD L Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
Page 6 o f 13
・ ・
Baystate Medical Center
Neurodiagnostics & Sleep Center
Electromyography
Springfield, Massachusetts 01199
Phone: 413-794-5688 Fux: 413-787-5713
Name: Stebbins, Richard
Study#: 13-129
Temp: Warmed throughout testing with hot pack and Accuwarm heating system to greater than 34°C
Medical Record #: 0339334
Date of Birth: 10/08/1978
Gender: Male
Referring Physician: Louis Adler, M.D.
Examining Physician: George D . Baquis, M.D.
Technologist: G B
Date of Exam: Height: 6'0"
Weight: 200lbs
04 Mar 13 08:14
Motor Nerve Conduction:
Nerve and Site • Latency Amplitude
Segment
Latency Difference Distance Conduction
• Velogity
Median.R
Wrist
3.3 ms
Elbow
7.8 ms
19.9 m
Wrist
19.4 mV Abductor pollicis brevis-
Wrist-Elbow
3.3 ms
4.5 ms
60 m m
240 m m / s
53 m/s
Ulnar.R
Ulnar (Across Wrist).R
Palm
Wrist
2.5 ms
3.8 ms
9.5 mV
86mV
FDI-Palm
Palm-Wrist
2.5 ms 1.3 ms 80 mm
65 mm
m/s
50 m/s
E-Wave Stydies
Nerve Median.R
Uinar.R
M-Latency 3.1
F-Latency 28.8
2.4
31.8
Wrist
2,6 mIS Ahductor digiti minimi-
Wrist
2.6 ms 60mm m/s
Below elbow 7.2 ms 112 mV Wrist-Below elbow 4.6 ms 54 m/s
Above cibow 9.8 ms Wrist-Above elbow 7.2 ms 250 mm
Axilla 1 2 . 0 m s Wrist-Axilla 9.4 ms 520 mi
380mm
53 m/s
55 m/s
INFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE. Page 1
Printed o n 11/13/2013 12:00 P M
STEBBINS JR,RICHARD L Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
: •
Sensory Nerve Conduction:
Nerve and Site :
Median.R Wrist
Elbow
Radial.R Forearm
Median.R
Mid palm (Median)
Ulnar.R
Mid paln (Ulnar)
Ulnar.R
Wrist
Below elbow
Above elbow
Ulnar.L
Wrist
Dorsal ulnar
cutaneous R
Forearm
Dorsal ulnar
cutaneous.L Forearm
Onset
Latency
Peak 1
Latency
Amplitude Segment
2 . 3 m s 3.1 mis 20jV
6.9 ms 8 . 0 m 12 HV
Digit I1 (index finger)-
Wrist
Wrist-Elbow
1.7 ms 2.2 ms 28HV Dorsum of hand.
Forearm
1.5 ms 1.9 ms 5 7 น า Wrist-Mid palm
I (Median)
1.4 ms
12 HV
Wrist-Mid palm (Ulnar)
2.1 ms
2.9 ms Il v
Digit V (little finger)-
6.6 ms
8 . 5 ก า ร
7.4 ms
9.8 m s
5 HV
Wrist Wrist-Below elbow
4 uV
Wrist-Above elbow
2 . 3 m ท ร 3 . 1 m s 17 pV Digit V (little finger)
Wrist
1.5 ms 2.0 ms 32gV Dorsum of hand-
Forearm
1.7 ms 2.2 ms
Latency
Difference
Distance
2.3 ms 140 mm
4.6 ms
265mm
1.7 ms 100 mm
1 . 5 ก า ร 80 mm
1.4 ms
2 . 1 m m s 120mm
4.5 ms
6.4 ms
280 m m
415 mm
2.3 ms
130mm
1.5 ms 80mm
Dorsum of hand-
Forearm 1 . 7 ก า ร 80 mm
INFORMATION IS CONFIDENTIAL. IIS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE.
Page 7 of 13
Conduction
: : Velocity
m/s
5 8 ก ป ร
60 m/s
m/s
m / s
6 3 m / s
6 4 m v / s
ท ป / ร
m/s
m/s
Page 2
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STEBBINS JR,RICHARD L
Page 8 of 13
Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
Needle EMG Examination:
Flexor cami
Triceps
Muscle
Aisertiona
Ins/Act Fibs spontaneous Activity
Fasic Other MUP Normal at activation Crutimel
Aerivation
MUP Configuration
Abductor Normal
Nonnal
Duration Amp Phase/ursPhase%s
poilicis brevis.R
Ist dorsal
interosseous.R Ahductor digiti
Normal
N o n m a i
Normal
minimi
(manus).R Extensor Normal
Normal
Normal
digitorum
communis.R
Normal
Flexor carni
ulnaris.R
Normal
radialis.R
Normal
Normal
N o r m a l
hrachii.R Biceps brachii.R Normal
Normal
Normal
Deltoid.R Normal
Normal
INFORMATiON IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE. Page 3
Printed on 11/13/2013 12:00 PM
STEBBINS JR,RICHARD L
Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
Nerve Conduction Testing
Normal Values
Yaner Extremity Values
Mator:
Nerve Record Amplitude Cond. Velocity Dist. Lat Dist.
( m V ) (m/sec) (msec.) (cm)
Median
APB
>= 4.0 >=49 <4.4 7
U i n a r ADM >= 6.0 >=49.
< 3.3
Sensory:
Nerve Record
Amplitude
uV) (m/seo) Cond, Velocity
Dist. Lat.
(misco)
Dist
(cm)
Median
(antidromic)
Digit 2 >= 20 >=56 * 3.5 12-14
Ulnar
(antidromic)
Digit 5 >=17 >055 <=3.1 10-12.
Radial
(antidromic)
Snuffbox >=20 7-50 =2.9 10.
Lat. Antebr.
Cutaneous
Forearm >12
< 2.6 1 2
Note: Consider iriterside comparison for ovaluation o f less commonly studied nerves
Mixed Falm fe Wrist Testing:
Norve Record Amplitude (uV)
Cond. Volocity DistLat
(m/scc)
(maoc).
Median Wrist >=50
= 50 2.2.
Ulnar Wrist >= 12
2.2
Dist.
(om)
* Significant latency difference is ≥s 0.4 msco
iNFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE
Page 9 of 13
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STEBBINS JR,RICHARD L Scan o n 9/18/2013 b y Sheila Rodrigo [998909] of Transfer Records
File Id: 0339334 Session: 2013-03-04 04 Mar 13 07:59
Nicolet Viking Select
Nicolet Biomedical
Rac. APG. Gom:Wist, Ebow Bayst. NA Rate:
Nan-Recurre
Moden
Right
Racord
07.5988
19.6 MA Dur
0.2 ms| Singl
Average: Of Sig. Echancer: 01
10tr
Recording Sio: Abductor policis brevis
Stimulus Ste
At: Wrist
iA2: Ebow
照 ⾨
5.7
7.aL 5.7
19.8
65.8
19.4
63.1
10 mer
Segment
Abductor policis brevis- Wrist
Whist-Ebow
2 4 G
Stebbina, Richard
R a c : I n d e r , B d m : W t i a l & E b o w B a y . . NRI
Rate: Non-Recument Levet Mittian
SNC
Record
03
19.6 mA Dur:
08.00:04
02 mis Single
verage: Of so. En
43,1mA Recording Ske: Digit I (odax Finger)
S i n u l u s S t e
At: Wrist
「 固
23
A2: Ebow
6.9 12
Segmen
Diot il finder fingar)-Wrist
Wrist-Eborr
140
265
232
58
Stabbine. Richard
0.7 Hz Levet
5 mv
N o car en mini (mRee
19.6 mA/Dur: 0.2 ms Singk
10 ms Trace: Hold / 1D
08
0800:10
f o r r y c 7 e
name
M - L a t 2.4 ms M-Amp: 11.7 m
22.0mh
22 aml
72.0m
Richard
TOP Rate:
Righ Meden F-waras
Inducer pallel brevts. Racord
82
0.7 Hz Level:
F-SNS: 500 uV
18.6 mA Dur: 0.1 me Single
10 ms Trace: Hold / 10
15 THA
[M-Lat ma M-Amp:
10 Ena
19 0mл
10 eind
18.00г
1 0 ร ท
75 m
25.7
Blebbing, Richard Roh
R e s A D M S t m L W , B . E B , 스 타 D , . A
65 Rate:
5 ml 300m7
VY, BE.AE Bayesse
Non-Recurrent Leval 19.6 mA | Our:
23 km
20 w
Recording Site: Digt V (Alle firger)
S d m i u s S t e
A1: Wrist
AZ: Below ebow
IA3: Above eDow
S e g m e e s
Diga V (allo Snger)-Wrist
tRans Weist-Balou elbowe
INFORMATION TE CONPIDENTIAL, IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR F
國
21
Page 10 of 13
0 8 . 6 9 .
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Page 11 o f 13
File Id: 0339334 Session: 2013-03-04 0 4 Mar 1308:02
Nicolet Viking Select Nicolet Biomedical
ins, Richard
fooll Redial
umnand, Sam: FLE
| Rate:
Record
14.7 ml Dor: 0.2 ms Singie
Average Or | Si. Ente
03.02:18
Recording Ste: Dorsum of hand
At: Foream
S n u u s S i e
m s , R i c h a r o Median
NRRate: Non-Recurrent Level
: U i n a r
Racord
08-02-22
14.7 mA Dur: 0.2 ms Single
1ms Slep
2 2 . 7 4 Recording Site A: Whist
Recording Sta B . Wist
Stralus Ste
At: Mid palm (Median)
(B2: Mid pet (Linar).
⾨ 飯 箱
1.5 1.9 57
1.4 20 12
37.1064
3 0 w
(Whist-Mid palm (Median) 80
W h i s l - M i d p a i n s ( U n a r ) 80 58
D a r s a l t n e r o u t a n e o u s
e : Dorumolhand, Stim: Forear.
Non-Recurrent Level
19.6 mADu 08:0228
Singla
Average: Or [Sin. Enhancer: O N
Recording Ste: Dorsum o f hand
Dorsum of hand-Forearms 100
Rec: Dorsemohand, Sint Foreat... Right Dorsal unar culaneous
Non-Recurrem Lovet" 19.6 MA TDx
Record
08.02-20
52 mel
Step:
Average: Off Sig. Enhancer: Of
Recording Ste: Dorsum of hand
Simuls Sta
Al: Forearm
Seoment
Dorum of hand-Foream
tebbins. Fichard
Uhar (Across Wries SUNC
Record
Non-Recuren Levet 18.6 mA Dor: 0.2 ms Single •+ as ama
1 rN Recordins Ste: FO
as sme S i w b S k e
(At: Pain
A 2 : W t
A5:
Segment
42
13)
解 務 四
1.7 48
08.02-12
RacDb.y SamWi. BE, A E Bayatase
/ Rate: Non-Recurrent
19.6 m A Dur: Record 08.02:35
0.2 ms] Single
Average: Oli Sa. Erhancer: C
3 0 W
Recording Sito: Digt V (telle Bingor)
95
8 6
限 .
21.2
19.9
Stimukus Sti
Al: Widel
A2: Beow ebow
A3: Above eDOW 23 3.1
20wv
Segment
2.5F
1.3 50
Wist-Below elbowe
Whist Above elbow
INFORMATION-18 CONFIDENTIAL. TYIS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
EAR DISCARE
Printed on 11/13/2013 12:00 P M
STEBBINS JR,RICHARD L
Page 12 of 13
Scan on 9/18/2013 by Sheila Rodrigo [998909] of Transfer Records
12/17/2012 9:13 AM Shields Health Care
1413-746-9700 2
BAYSTATE
MRI S IMAGING CENTER
Baystate MRI - Springfield
Patient: Stebbins, Richard Jr
Home:413-949-1925
MRN: 4238158
DOB: Oct 8 1978 (Age 34 at exam)
FINAL Diagnostic Imaging Report
Sent To: Karas, Sumner E M D
300 Birnie Ave/Ste 201
Att: Peter Michaud PA
Springfield MA 01107
Accession 4238158.1
Exam date Dec 14 2012
Exam time 07:30 pm
Procedure MRI - Cervical Spine (C-) CPT 72141
Referring Physician: Karas, Sumner E MD
120150. an 2012 ram in producel Spine (C) CP 72141
Room Description: Bay Siem Espr 2 1.5:
MRI Technique:
Sag T1, Sag T2, Sag PD, Axial T2, Axial T 2 GRE
Report
HISTORY: Degenerative disc disease cervical spine. Right-sided back pain and muscle spasm. Pain extending down the right arm.
COMPARISON: No prior studies are available for comparison at Baystate MRI and Imaging Center.
FINDINGS: The cervical spine is subtly convex to the left, and
cervical straightening of the cervical spine is noted without subluxation. The vertebral bodies are normal in height and signal. Subtle loss of cervical disc space height is seen, and this is most pronounced at C6-C7. Minimal marginal spurring is noted at this level.
The visualized posterior cranial fossa structures are unremarkable. No cord compression or cord signal abnormality is seen.
The paraspinal soft tissues are unremarkable.
C2-C3: No central canal or foraminal stenosis.
C3-C4: No central canal or foraminal stenosis.
C4-C5: No central canal or foraminal stenosis.
INFORMATION IS CONFIDENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE
1 of 2 - Richard Jr Stebbins - Accession: 4238158.1 - Exam Date: Dec 14 2012
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STEBBINS JR,RICHARD L
Scan on 9/18/2013 b y Sheila Rodrigo [998909] of Transfer Records
12/17/2012 9:13 AM Shields Health Care
1413-746-9700
C5-C6: No central canal or foraminal stenosis.
C6-C7: Mild broad-based posterior disc bulge with marginal osteophytes, Minimal indentation of the ventral thecal sac. Mild right and no left foraminal narrowing.
C7-T1: No central canal or foraminal stenosis.
IMPRESSION:
1. Mild spondylotic and degenerative disc changes of the cervical spine are present at C6-C7 with mild right-sided foraminal narrowing. No cord compression is seen.
2. Straightening of the cervical spine which may be secondary to positioning or muscle spasm.
Electronically signed by Eugene Kang MD on Dec 17 2012 at 9:02 a.m
INFORMATION IS CONFIBENTIAL. IT IS PROVIDED
AS AUTHORIZED BY THE PATIENT/CLIENT. NOT
FOR DISCLOSURE.
2o12 - Richard Jr Stebbins - Accession: 4238158.1 - Exam Date: Dec 14 2012
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