ipl-logo

Carpal Tunnel Syndrome Case Summary

388 Words2 Pages
bulb-icon

Recommended: Essays on how to prevent from shoulder injuries

DOI: 07/27/2006. Patient is a 36-year-old female apprentice engineer who sustained an injury to her neck and back due to lifting of hall demolition debris. Per OMNI entry, she is diagnosed with chronic back sprain/strain.
Urine drug screen obtained on 04/05/16 revealed positive for hydrocodone and Flexeril.
Per the progress report dated 09/06/16, patient complained of low back pain. Her medications are Norco 5/325mg, Motrin 800mg, and Flexeril 7.5mg.
Based on the progress report dated 10/04/16, the patient states that "today the pain is somewhere 4-5 with the help of medication, but patient states that I cannot sleep on my stomach because of the pain."
On examination of the cervical spine, there is slight tenderness at the trapezius on deep …show more content…

Tinel’s sign and Finkelstein’s test is positive. There is evidence of carpal tunnel syndrome.
On examination of the lumbar spine, there is slight tenderness at L4-L5 and L5-S1. Heel and toe ambulation could not be conducted because of instability and pain. Range of motion (ROM) shows bilateral lateral flexion at 30 degrees and bilateral lateral rotation at 40 …show more content…

Knee and ankle jerks are 1+, bilaterally. There is weakness of the quadriceps, hamstrings as well as the flexors and extensors of the hips.
Assessments include cervical sprain, lumbar sprain, constipation, left carpal tunnel syndrome, lumbar degenerative disc disease, and retrolisthesis at L5-S1. Patient was given prescription for Norco 5/325 mg one tablet twice daily for severe pain #60, Motrin 800 mg 1 tablet twice daily as needed for inflammation and pain #60 and Flexeril 7.5 mg 1 tablet at bedtime for muscle relaxation #30.

Requested from the provider’s office copies of recent urine d rug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no reports were received prior to the submission of this request to PA.
Patient has been previously certified with 45 Tablets of Norco 5/325 mg and denied with 60 Tablets of Motrin 800 mg and 30 Capsules of Flexeril 7.5 mg on 09/13/16 ( Review 275436).

Current request is for 30 Tablets of Flexeril 7.5 mg; 60 Tablets of Norco 5/325 mg; and 60 Tablets of Motrin 800 mg between 10/11/2016 and

Show More
Related
934 Words | 4 Pages

2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications.

Read More
302 Words | 2 Pages

An MRI was performed of the lumbar spine. The examination found no significant extra

Read More
647 Words | 3 Pages

Pain radiates from the lower back and aggravated by bending, getting in and out of the car, lifting, reciprocating stairs, sitting, standing, turning, twisting and walking which is mildly alleviated by over-the-counter drugs and

Read More
859 Words | 4 Pages

QEP Scripts for Two Recordings – Audio for Musculoskeletal System; “OK, Team! We have a new patient in Room 3B who is being admitted with a progressive (gradual, advancing) decrease in mobility (movement) of his back and legs, and increase in pain located in the lumbosacral (lower back above the tailbone of the spine) area. The patient’s Primary Care Provider has sent along Computed Tomography scans (CT, a rotating x-ray emitter, detailed internal scanner) showing spinal stenosis (narrowing of the spine causing pressure on the nerves and spinal cord causing lower back pain.) and decrease of the normal lordosis (abnormal curvature lower spine, excessive inward curvature of the spine) in the thoracic vertebrae (upper and middle back). Lumbosacral

Read More
284 Words | 2 Pages

Review of systems is positive for heat/cold intolerance, skin rash, new growth or mole, snoring, ankle swelling, abdominal pain, nausea, muscle pain, muscle weakness and difficulty sleeping. As of this report, an 11-panel urine drug screen was administered on this visit and showed positive for oxycodone. Patient continues with failed back and radicular pain for several years and failing adjuvant and increasing tolerance. A second opinion was advised and proceed with surgery if needed, or a trial of spinal cord stimulator.

Read More
362 Words | 2 Pages

Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. He had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. He continues to have good strength with normal bulk and tone throughout his extremities.

Read More
312 Words | 2 Pages

Based on progress report dated 05/23/14, the patient reports of continued dull aching pain and burning sensation into the cervical spine. She received 2 cc of lidocaine with no epinephrine in the bilateral trapezius, cervical rhomboid, and cervical paraspinal muscles on this visit. Based on progress report dated 07/10/15, the patient complains of unchanged, sharp, dull and aching pain in the cervical spine, which radiates to the bilateral upper extremities. Baseline is 6-7/10 pain. Rest and medications help alleviate the pain.

Read More
340 Words | 2 Pages

Per progress report dated 10/23/14 medicatiosn include Atenolol, Norco and cyclobenzaprine. Based on progress report dated 07/06/15, the patient presents with chronic right knee pain, described as dull and achy. Pain is worsened by sittlng,standing, and walking, and relieved by walking/exercise. He has been weaning norco and flexeril.

Read More
829 Words | 4 Pages

Page’s patient, P, suffers from back pain and he is determined to find the cause of the pain. To rule of the most lethal causes of back pain, some of the questions Page asks include “Did the pain wake him up at night? Was it worse when he was lying down? Had he recently lost weight?” (Page).

Read More
746 Words | 3 Pages

That is the hand surgeon will talk to the patients and investigating the arm. The carpel tunnel syndrome can cause you can wake up at the night time and you have the irritation, numb or the hand tingling. If you can flick your hands, you can get away from the numbness. The studies of the nerve conduction explain, the diagnosis of carpel tunnel syndrome is the best way to get rid of the problems. One of the major things you have to consider there are 20% to 33% of the carpel tunnel syndrome diagnosis will be failed.

Read More
401 Words | 2 Pages

Studies have shown that there are many causes/risk factors that go along with carpal tunnel syndrome. The first cause/risk factor would be an anatomic injury.

Read More
830 Words | 4 Pages

In this disorder, night time symptoms are common because a lot of people sleep with their wrists bent which makes the symptoms worse and causes severe pain. Also, when he plays the piano for an extended period of times, he is constantly flexing and extending his

Read More
1379 Words | 6 Pages

Substance History: Mr. Fountain reports that he drinks alcohol infrequently. He estimated drinking less than 6 beers in the past month. He avoids mixing alcohol with his prescription pain medications. He quit smoking tobacco in 2001. Previously, he smoked 1 pack of cigarettes per day for approximately 10 years.

Read More
879 Words | 4 Pages

A common posture that individuals adapt under these conditions is “postural depression.” Postural depression consists of a hunched back with a forward position of the head and shoulders. Poor postures increase the likelihood of individuals developing trigger points in these areas. Trigger points associated with symptoms of carpal tunnel syndrome are located in the coracobrachialis, biceps brachii, and subscapularis muscles. “Postural depression” also increases the likelihood adopting a “chest breathing” pattern.

Read More
1513 Words | 7 Pages

For over a decade, acute and chronic back pain has been treated with opioid analgesics also known as opiates or narcotics (such as Percocet or Oxycontin), and nonopioid analgesic, including NSAID’s (such as Naproxen and Ibuprofen). On average, 182,727,272 opioid analgesic prescriptions are dispensed annually (Dal Pan, 2016). Unfortunately, each of which is accompanied by potentially serious adverse effects.

Read More

More about Carpal Tunnel Syndrome Case Summary

Related Topics

Open Document