DOI: 6/25/2007. Patient is a 37-year-old female store manager who sustained injury when a tote slipped off shelf and struck her left side of the body. Per OMNI, she is status post ulnar nerve decompression on 03/11/08, left De Quervain’s release on 09/08/09, spinal cord stimulator implant on 08/03/11 and shoulder surgery on 01/19/15.
Per the PT attendance report dated 05/07/15, the IW has attended a total of 30 sessions for the left shoulder from 02/05/15 through 05/01/15.
Based on the medical report dated 06/24/16 by Dr. Angermeier, the patient presents for evaluation of left hand numbness and tingling. She has history of left ulnar nerve decompression approximately 6 years ago. She also has history of both left upper and lower
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She has elbow range of motion actively from 15 to 150 degrees. She is exquisitely tender to touch throughout the medial elbow and distal forearm. There are some trophic skin changes consistent with her diagnosis of complex regional pain syndrome. She has subtle weakness of the intrinsic function in her hand. There is a 2 point discrimination of 8mm and ulnar nerve distribution, 4 mm in the median nerve distribution.
Current medications include Xanax, Symmetrel, Amrix, Flexeril, Relpax, Duragesic patch, Fentanyl, Prevacid, Movantik, Zofran, Roxicidone, Prevident, Trezix, Chantix, Zorvolex and Vitamin
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She continues to have active symptoms of complex regional pain syndrome in the left upper extremity, which at this point may never resolve. Recommendation was made for continued conservative treatment, although IW was counseled that she may well have progression of ulnar neuropathy over time which could also have significant consequences for her with respect to pain, numbness, tingling, and weakness or deformity of the hand. Unfortunately, MD thinks that the IW’s risk of complications with revision surgery probably outweigh the risk of progression of her ulnar