DOI: 1/20/2016. Patient is a 62-year-old right hand dominant female sonographer/cardiovascular technician who sustained bilateral pain and numbness of hands, left arm and shoulder due to repetitive movement. Per OMNI, the patient had bilateral carpal tunnel syndrome, left rotator cuff tendinitis, and strained muscles and tendons of the left rotator cuff.
Per the medical report dated 07/19/16, the patient is being evaluated for her progressive paresthesias in both hands along the median nerve distribution, involving the thumb, index, and long fingers, especially when she performs repetitive activities. She has most of her numbness and tingling throughout the day. She has already been treated conservatively with the use of splints and ibuprofen. …show more content…
Sensory perception is as follows: thumb, 7/7, index, 6/6; long, 6/5; ring/small, 5/5.
Grip/pinch strengths show 40/40/40, with elbow extended.
Carpal Tunnel compression test, Carpal tunnel Tinel's, Phalen’s and Reverse Phalen’s are positive.
Current medications include valsartan, duloxetine, alprazolam, Keflex and Norco.
Assessments are right carpal tunnel syndrome and status post left endoscopic carpal tunnel release with residual pillar pain.
The patient has failed conservative treatment including splinting, therapy, nonsteroidal anti-inflammatory, and steroid injection which was given on 06/13/16.
Plan is for right endoscopic carpal tunnel release, as the IW has continued tingling and numbness despite conservative treatment.
Patient wishes to continue. Postoperatively, the patient will be a candidate for therapy at 2 times a week for 3 weeks. She is prescribed Keflex 500 mg one tablet 4 times a day x 3 days and Norco 5/325 mg for moderate to severe pain postoperatively.
The patient will continue with a home exercise program to strengthen the left upper extremity. She is prescribed a silicone wrist wrap to help minimize pillar pain.
Current request is
Per the medical report dated 07/19/16, the patient is being evaluated for her progressive paresthesias in both hands along the median nerve distribution, involving the thumb, index, and long fingers, especially when she performs repetitive activities. She has most of her numbness and tingling throughout the day. She has already been treated conservatively with the use of splints and ibuprofen. …show more content…
Sensory perception is as follows: thumb, 7/7, index, 6/6; long, 6/5; ring/small, 5/5.
Grip/pinch strengths show 40/40/40, with elbow extended.
Carpal Tunnel compression test, Carpal tunnel Tinel's, Phalen’s and Reverse Phalen’s are positive.
Current medications include valsartan, duloxetine, alprazolam, Keflex and Norco.
Assessments are right carpal tunnel syndrome and status post left endoscopic carpal tunnel release with residual pillar pain.
The patient has failed conservative treatment including splinting, therapy, nonsteroidal anti-inflammatory, and steroid injection which was given on 06/13/16.
Plan is for right endoscopic carpal tunnel release, as the IW has continued tingling and numbness despite conservative treatment.
Patient wishes to continue. Postoperatively, the patient will be a candidate for therapy at 2 times a week for 3 weeks. She is prescribed Keflex 500 mg one tablet 4 times a day x 3 days and Norco 5/325 mg for moderate to severe pain postoperatively.
The patient will continue with a home exercise program to strengthen the left upper extremity. She is prescribed a silicone wrist wrap to help minimize pillar pain.
Current request is