DOI: 8/20/2009. Patient is a 65-year-old female stocker who sustained injury to her bilateral hand and wrists from performing her job duties. As per OMNI entry, she was diagnosed with carpal tunnel syndrome, status post carpal tunnel release; and trigger fingers. IW was deemed at maximum medical improvement (MMI) by QME Dr. Choi on 06/20/13 with 0% permanent disability and on 07/14/16, with 0% whole person impairment.
Based on the progress report dated 04/28/16, the patient complains of soreness of the right palm and pain in the right thumb. Patient has loss of strength and mild cramping, bilaterally. Review of systems is positive for fatigue, weight gain/loss, blurred vision, congestion, ringing in the ears, arrhythmia, high blood pressure, …show more content…
Daily activities like lifting are difficult due to pain with movements of the upper extremities. Her pain causes loss of sleep. Patient can walk 2 blocks before stopping due to pain. She can stand for 30 minutes before having to sit down due to pain. She avoided exercising/recreation during the past month due to pain. Treatments tried include surgery and PT, both with moderate relief. Review of systems is positive for blurred vision, ringing in the ears, sinus problems, chest pain, swelling of feet and ankles, shortness of breath, abdominal pain, constipation, nausea, anemia, difficulty walking, joint pain, muscle aches/cramps/weakness, dizziness or light headedness, frequent headaches, memory loss, poor balance, tingling, depression, excessive thirst, heat/cold intolerance, frequent urination and urinary urgency. On examination of the wrist, range of motion is restricted with palmar flexion, dorsiflexion, ulnar deviation, radial deviation, supination and pronation. Movements are painful with dorsiflexion, ulnar deviation, radial deviation, supination and pronation. There is tenderness to palpation noted over the anatomical snuffbox, scapholunate articulation and triangular fibrocartilage complex. There is pain sensation present over the right wrist. Patient appears to be in moderate distress. Current medications include Baclofen compound, Diclofenac 1.5% topical solution and Tylenol with
Based on the progress report dated 04/28/16, the patient complains of soreness of the right palm and pain in the right thumb. Patient has loss of strength and mild cramping, bilaterally. Review of systems is positive for fatigue, weight gain/loss, blurred vision, congestion, ringing in the ears, arrhythmia, high blood pressure, …show more content…
Daily activities like lifting are difficult due to pain with movements of the upper extremities. Her pain causes loss of sleep. Patient can walk 2 blocks before stopping due to pain. She can stand for 30 minutes before having to sit down due to pain. She avoided exercising/recreation during the past month due to pain. Treatments tried include surgery and PT, both with moderate relief. Review of systems is positive for blurred vision, ringing in the ears, sinus problems, chest pain, swelling of feet and ankles, shortness of breath, abdominal pain, constipation, nausea, anemia, difficulty walking, joint pain, muscle aches/cramps/weakness, dizziness or light headedness, frequent headaches, memory loss, poor balance, tingling, depression, excessive thirst, heat/cold intolerance, frequent urination and urinary urgency. On examination of the wrist, range of motion is restricted with palmar flexion, dorsiflexion, ulnar deviation, radial deviation, supination and pronation. Movements are painful with dorsiflexion, ulnar deviation, radial deviation, supination and pronation. There is tenderness to palpation noted over the anatomical snuffbox, scapholunate articulation and triangular fibrocartilage complex. There is pain sensation present over the right wrist. Patient appears to be in moderate distress. Current medications include Baclofen compound, Diclofenac 1.5% topical solution and Tylenol with