Carpal Tunnel Syndrome Case Summary

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DOI: 06/04/2008. The patient is a 61-year-old female dispatcher who sustained a work-related injury to her right hand and arm due to repetitive duties. As per OMNI entry, she is status post right proximal median nerve decompression on 05/12/11 and right carpal tunnel release on 09/26/11.
Per progress report dated 8/12/16, the patient was seen for her chronic neck pain and bilateral wrist pain. Current medications include Norco, Neurontin, Lisinopril, propranolol, clonazepam, fexofenadine, Asmanex, Nasonex, Relpax, Prozac, and Patard.
Based on the progress report dated 10/07/16, the patient presents for evaluation of carpal tunnel syndrome on the right shoulder.
The patient states that she continues to have pain, every single day. Her shoulder pain has started to radiate up to her neck. Shoulder pain is rated to a 9/10 without medications, and 5/10 with medication. Because of the cold weather, she has started to complain more and more of pain this week. She is sleeping fair 6 hours, uninterrupted. The patient stated that she goes to the gym 3 times a week for an hour and a half, and she works …show more content…

The patient was advised to take less medication and start weaning herself off of it as possible, and this is all in due to protect her kidneys and liver function and also a second prescription was given for Norco 10/325 one tablet twice daily #60 with "Do Not Refill or Do Not Dispensed Until 11/06/2016. The patient is to continue going to the gym and working on her stretching and strengthening exercises. Acupuncture 2 visits a week for 4 weeks for a total of 8 visits for her right shoulder is also requested, since she is starting to get more pain and this is limiting her activity such as vacuuming, and she is taking more medications because of increased pain. POMI (Patient Opioid Misuse Index) score shows 1/6, indicating the patient is not a potential misuser of

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