DOI: 5/9/2011. The patient is a 63 -year-old female contract buyer who sustained a work-related injury due to computer/typing duties. The patient is status post left wrist endoscopic carpal tunnel release, first dorsal compartment release, second dorsal compartment release and tenosynovectomy and arthroscopy and excision of central triangular fibrocartilage complex tear on 08/25/14 and right wrist arthroscopy and excision of central triangular fibrocartilage complex tear, carpal tunnel syndrome, first and second dorsal compartment tenosynovitis and lunotriquetral ligament partial tear on 01/25/16.
Based on the progress report dated 05/26/16, the patient presents for follow-up of her bilateral upper extremity complaints. Since her last visit, she states an increase in pain and inflammation to both her arms. She reports that she has aching pain that radiates up the arms, equal in both sides. Pain is rated as 9/10. She has numbness into the hands extending to her fingers. She reports weakness to both her hands, making it difficult to grab objects. The patient states that most movements and use of her hands aggravate the symptoms, such as playing cards or using a computer. Rest minimally alleviate symptoms. She wakes up in pain, but does not …show more content…
Range of motion is limited, pain-free. There is moderate tenderness over the thenar eminence. Tinel’s test is positive. Grip strength is 4/5.
Current medications include Tylenol #3, Capsaicin cream and Norco 5/325 mg. The patient reports that the cream provides no relief.
Diagnoses include bilateral carpal tunnel syndrome, bilateral wrist pain, left side cubital tunnel syndrome and bilateral hand pain. Patient will continue Norco and will trial a Ketoprofen cream as needed for pain and inflammation and Flexeril 7.5 mg daily as needed for spasm.
She was given a prescription for Ketoprofen cream 20% and cyclobenzaprine 7.5 mg. She will follow-up in 4
Based on the progress report dated 05/26/16, the patient presents for follow-up of her bilateral upper extremity complaints. Since her last visit, she states an increase in pain and inflammation to both her arms. She reports that she has aching pain that radiates up the arms, equal in both sides. Pain is rated as 9/10. She has numbness into the hands extending to her fingers. She reports weakness to both her hands, making it difficult to grab objects. The patient states that most movements and use of her hands aggravate the symptoms, such as playing cards or using a computer. Rest minimally alleviate symptoms. She wakes up in pain, but does not …show more content…
Range of motion is limited, pain-free. There is moderate tenderness over the thenar eminence. Tinel’s test is positive. Grip strength is 4/5.
Current medications include Tylenol #3, Capsaicin cream and Norco 5/325 mg. The patient reports that the cream provides no relief.
Diagnoses include bilateral carpal tunnel syndrome, bilateral wrist pain, left side cubital tunnel syndrome and bilateral hand pain. Patient will continue Norco and will trial a Ketoprofen cream as needed for pain and inflammation and Flexeril 7.5 mg daily as needed for spasm.
She was given a prescription for Ketoprofen cream 20% and cyclobenzaprine 7.5 mg. She will follow-up in 4