Carpal Tunnel Note

Age: Occupation:
Involved Side: Sports:
Date of Injury:

Chief Complaint
hand tingling and numbness
History of Present Illness
M is a year old retiree seen at the request of Dr. for evaluation of the wrist.
Pain Severity: /10 Pain location:
Pain at rest: /10 Exacerbating factors: activity
Pain with activity: /10 Ameliorating Factors: rest
Pain Duration:
Pain night:
Previous treatment:

PMH: none
PSH: none
Family History: Patient questionnaire was reviewed, signed and dated in the chart and was noncontributory.
Medications: none
Allergies: NKDA
Social History: no smoking, no alcohol use
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no known metal allergies.

Physical Exam
Height: Weight: Pulse: 80 BP:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: normal Coordination: normal
Wrist / Hand Exam (Bilateral)
Inspection/Palpation (R/L): nontender, no effusion bilaterally
Wrist Flexion_(R/L): 55 / 55 Wrist Extension_(R/L): 45 / 45
Radial Deviation (R/L):12 / 12 Ulnar Deviation (R/L): 30 / 30
Hand Function: Able to A-OK, Hook horns, cross fingers, thumbs up bilaterally
Wrist Stability (R/L): no instability bilaterally
Wrist Flexion (R/L): 5/5 / 5/5 Wrist Extension (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Lymph UE (R/L): no axillary lymphadenopathy
DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+)
Durkins compression = worsening numbness in median nerve distribution
Phalens test = worsening numbness in median nerve distribution
Tinel's at carpal tunnel = tingling in median distribution
Tinel's at cubital tunnel = normal
Knee Exam (Bilateral)
Inspection / Palpation LE (R/L): non-tender bilaterally
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature: 2+ dorsalis pedis pulse bilaterally
LE Skin: no rashes or lesions bilaterally
Lymph LE: no inguinal lymphadenopathy
DTR LE: Patellar (2+/2+); Achilles (2+/2+)

Diagnostic Studies
Wrist films taken today were personally evaluated by me and demonstrate normal carpal alignment without significant degenerative changes.
Assessment
Right Carpal Tunnel Syndrome (354.0)
Plan
We discussed the natural history and both operative and non-operative treatment options. We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment. All questions were answered. Available links to further peer-reviewed written information on the diagnosis were provided. We will begin treatment with a cock-up wrist splint as well as a naprosyn prescription. An EMG was order to further evaluate median nerve function. They will follow-up in 4-6 weeks for continued evaluation and management.

Occupation:
Sport:
Involved Side:
Injury:
HPI: 45y/o RHD female with gradually worsening right numbness and tingling over several months. Minimal pain. Tingling is worse with activity such as writing. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications: none
Allergies: none
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Skin / Lymph within normal limits
Durkins compression = worsening numbness in median nerve distribution
Phalens test = worsening numbness in median nerve distribution
Tinel's at carpal tunnel = tingling in median distribution
Tinel's at cubital tunnel = normal
Flexion(R/L): 55 / 55
Extension (R/L): 45 / 45
Radial deviation (R/L): 12 / 12
Ulnar deviation (R/L): 30 / 30
able to A-OK, hook horns, cross fingers, thumbs up
subjective normal M/U/R distal sensation
2+ Radial pulse
Xray: no osseous deformity
EMG: none
ASSESSMENT: Carpal Tunnel Syndrome (354.0)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
activity modifications
Cock-up wrist splint
NSAIDS
Information sheet given
Follow-up 6-8 weeks