DOI: 8/19/2010. Patient is a 35-year-old right hand dominant female enrollment specialist who sustained injury to her right upper extremity due to regular job duties. Per OMNI, she was diagnosed with right carpal tunnel syndrome.
Electrodiagnostic evaluation dated 11/29/10 revealed mild right carpal tunnel syndrome; mild chronic right C6-C7 radiculopathy; no clear evidence of right C5 or C8 radiculopathy; or of right ulnar neuropathy.
Per the acupuncture progress report dated 08/20/15, the patient has attended 8 sessions for her right arm/shoulder.
MRI of the right wrist obtained on 01/11/16 showed a variant ulnar anatomy and lunotriquetral coalition and probable tear of the scapholunate ligament.
Per the medical report dated 02/12/16, …show more content…
Based on the progress report dated 03/25/16, the patient is doing much better with wrist and carpal strain in the presence of a congenital carpal coalition. She was advised to wean off the splint.
Based on the progress report dated 06/20/16, the patient has a proximal row coalition with her scaphoid and lunate. She has pain mostly over the scaphotrapezotrapezoidal (STT) joint.
On examination, patient is still sore mostly over the radial aspect of the carpus, primarily over the STT joint. She has some irritability. She has some stiffness in her wrist. Her contralateral side is about 65 degrees of extension and flexion; however, on the affected side, she is close to 50 degrees. She has irritability with Watson’s test. Impression is wrist strain with increased stresses, likely secondary to right sided carpal coalition and overuse. Patient would like to proceed with wrist arthroscopy. Plan is for wrist arthroscopy and mid carpal arthroscopy and her chondral surfaces will be evaluated, and this can stage her further treatment.
Current request is for 1 Right Wrist Mid Carpal Joint Arthroscopy with Debridement between 7/11/2016 and
Electrodiagnostic evaluation dated 11/29/10 revealed mild right carpal tunnel syndrome; mild chronic right C6-C7 radiculopathy; no clear evidence of right C5 or C8 radiculopathy; or of right ulnar neuropathy.
Per the acupuncture progress report dated 08/20/15, the patient has attended 8 sessions for her right arm/shoulder.
MRI of the right wrist obtained on 01/11/16 showed a variant ulnar anatomy and lunotriquetral coalition and probable tear of the scapholunate ligament.
Per the medical report dated 02/12/16, …show more content…
Based on the progress report dated 03/25/16, the patient is doing much better with wrist and carpal strain in the presence of a congenital carpal coalition. She was advised to wean off the splint.
Based on the progress report dated 06/20/16, the patient has a proximal row coalition with her scaphoid and lunate. She has pain mostly over the scaphotrapezotrapezoidal (STT) joint.
On examination, patient is still sore mostly over the radial aspect of the carpus, primarily over the STT joint. She has some irritability. She has some stiffness in her wrist. Her contralateral side is about 65 degrees of extension and flexion; however, on the affected side, she is close to 50 degrees. She has irritability with Watson’s test. Impression is wrist strain with increased stresses, likely secondary to right sided carpal coalition and overuse. Patient would like to proceed with wrist arthroscopy. Plan is for wrist arthroscopy and mid carpal arthroscopy and her chondral surfaces will be evaluated, and this can stage her further treatment.
Current request is for 1 Right Wrist Mid Carpal Joint Arthroscopy with Debridement between 7/11/2016 and