Carpal Tunnel Syndrome Case Studies

Satisfactory Essays
DOI: 9/30/2014. Patient is a 28-year-old female research assistant who alleges pain and weakness in her hands/wrist as a result of repetitive scooping dirt from soil barrels. As per OMNI entry, the patient was diagnosed with cervicobrachial syndrome (diffuse), right carpal tunnel syndrome and insomnia. She is status post endoscopic carpal tunnel release (CTR) on 09/24/2015 for the right and on 06/02/2015 for the left side. Per office visit notes dated 8/7/2016, patient presents for a follow up for neck pain, left elbow pain and bilateral wrist pain. Current medications include Naprosyn EC 500 mg, Tramadol 50 mg, Lyrica 50 mg and Levora-28 0.15/0.03 mg. Patient was recommended retrial of Celexa for her depressed mood related to her chronic…show more content…
He was given a prescription for Naproxen 500 mg twice daily #60 with some moderate pain relief and can tolerate therapy with use. He will continue Ultram 50 mg daily as needed, #30 as she notes improvement in activity tolerance and post-exercise recovery, and improvement in her pain and is able to work. Functional improvement is noted. He will continue Lyrica 50 mg twice daily for increasing neuropathic pain of bilateral upper extremities with prior carpal tunnel release surgeries. She notes improvement in numbness/tingling of her upper extremities and is helping her rest. Patient will also continue Celexa 20 mg daily for her depressed mood related to her chronic pain state and she notes improvement in her mood. Of note, Controlled Substance Utilization Review and Evaluation System (CURES) report ran 9/17/2016 and is appropriate for previous prescriptions and providers. Urine drug screen was completed in clinic and was consistent from 3/2016 and repeated on 6/16/16 and showed positive for Ultram. Patient remains consistent. Lidoderm patch 5% topically was discontinued due to poor
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