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Carpal Tunnel Syndrome Case Summary

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DOI: 4/25/2016. Patient is a 43-year-old right-hand dominant female housekeeper/maintenance worker who alleges repetitive injury to both wrists. Per OMNI entry, she was diagnosed with bilateral carpal tunnel syndrome. She has undergone PT.
Electromyography/nerve conduction studies of the upper extremities dated 05/17/2016 demonstrated moderate right sensorimotor median nerve neuropathy at the wrist consistent with carpal tunnel syndrome. There is also mild left carpal tunnel syndrome. There is no evidence of cervical radiculopathy at this time.
Based on the latest medical report dated 09/27/16 by Dr. Krishna, the patient reported having progressive weakness into the bilateral wrists/hands with numbness and tingling sensation and dysesthesias. …show more content…
She states that at night time, her hands are numb and awakens her often to lift/move her arm. The patient states that she easily drops objects because of pain and weakness, "arms get heavy". The patient states that she has been working in housekeeping/maintenance and office cleaning for 15 years with ongoing repetitive motion to the bilateral hands. Her pain is exacerbated by carrying heavy objects, pushing, pulling and lifting. The patient is working full-time/full-duty as a housekeeping. She is not receiving physical therapy; but she is using Pennsaid topical cream.
There is a past medical history significant with a ganglion cyst in the left wrist which is treated with aspiration. Her left wrist have resolved after the aspiration procedure. She is currently wearing a wrist splints which is helpful. She has seen an orthopedist and waiting for surgery intervention with Dr.

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