Carpal Tunnel Syndrome Case Study

DOI: 5/12/2011. The patient is a 55-year-old female business analyst who sustained injury from repetitive keyboard use. The patient is subsequently diagnosed with major depressive affective disorder, moderate anxiety disorder, hyperlipidemia and chronic pain. Per OMNI, the patient is status post left carpal tunnel syndrome surgery on 12/28/11, right carpal tunnel syndrome surgery on 5/15/12, left ulnar cubital surgery 5/7/13 and right cubital surgery on 7/9/13. As per office notes dated 03/12/2016 revealed that the patient stated that she has had 4 surgeries for carpal tunnel syndrome and did not work, she has been in chronic pain for 4 years. She has experienced depressed mood, loss interest, anxiety and insomnia since then. Mental examination revealed anxious
mood and affect. As per office notes dated 3/30/16, the patient is for evaluation of her bilateral upper extremity pain.
She is doing a little bit better. She has been taking some anxiety medication and sleep medication that has been helpful. She is also taking Norco. She alternates gabapentin with Lyrica and takes tramadol with good relief and tolerates it well. Lyrica provides better relief, but it was mentioned that she will take gabapentin since she was difficulty getting her prescriptions. She has aching pain from the elbows down to the wrist with numbness and tingling in the 4th and 5th ginger and hypersensitivity of the entire arm as well as weakness. Pain levels are 7-8/10 without medication, coming down to 2-3/10 with medication. Her pain is worse with walking, bending, and lifting. It is decreased with sitting, standing, lying down, and medication. Functional improvements, she has been more active this past month. She has been exercising more with her medication. She can use her arms and hands and do her household chores and stay active. Previous medications that have been tried and failed are Cymbalta and Lexapro which caused significant side effects. The patient also experiences migraines, numbness, and
headaches. Review on psychological system revealed that patient is positive for depression, anxiety, insomnia, and dizziness. Right and left upper extremity exam revealed a little less sensitivity of the forearm and wrist. There is tenderness at the medial epicondyle. Neurological sensation is decreased in 4th and 5th finger. Grip strength is 5-/5 bilaterally. Shoulder abduction bilaterally is 5/5. Elbow extension is 5/5. Wrist extension on the right is 5/-5, left is 5/5. Elbow flexion is 5/5 bilaterally. Finger abduction is 5/5 bilaterally. The patient also has erythematous papular rash of upper extremities. Current medications include Norco, gabapentine, tramadol extended release, BuSpar, Lorazepan as per Dr. “Do”, and sleeping medication as per Dr. “Do”. Call was made to ask for the recent office notes after 3/30/16; however, no additional medicals were received prior to sending to peer. Urine drug screen dated 3/2/16 is attached to this review.