New Patient Note (Hand Surgeon)

Diagnosis and treatment summary: 1. Carpal Tunnel Syndrome 2. Trigger Finger Occupation: - Office worker Diagnostic Studies: - X-rays: No evidence of fracture, malalignment, dislocation, or other bony lesion. X-rays were obtained in the setting of trauma and pain. - Ultrasound: Not performed - CT scan and MRI: Not performed Past Medical History: - Hypertension - Appendectomy in 2010 - Family history of diabetes - Medications: Lisinopril - Social history: Non-smoker, occasional alcohol use - Allergies: Penicillin History of present illness: - Patient presents with numbness and tingling in the right hand, particularly affecting the thumb, index, and middle fingers. Symptoms have been worsening over the past three months, especially during work hours. - Associated symptoms include occasional pain in the wrist and difficulty gripping objects. Physical Examination: - Vitals: Blood pressure 130/85 mmHg, heart rate 72 bpm - Neurological: Sensory is intact to light touch in the median, radial, and ulnar nerve distributions in the hand and in all digits. Katz hand diagram shows classic distribution of symptoms. Motor exam is intact IO/OP/EPL/FDP-index. While sensation is intact, there is subjective decrease in the median nerve distribution with positive Tinel, positive median nerve compression test, and swelling over the distal volar forearm and wrist on the left side. No intrinsic or thenar atrophy. Worsen symptoms with sustained repetitive gripping. 2 point discrimination greater than 7mm in median nerve distribution versus 5mm in ulnar nerve distribution. - Musculoskeletal System Exam: Examination reveals intact extensor and flexor function at the hand, wrist, and elbow. There is no evidence of stiffness at the MP, PIP or DIP joints. There is no evidence of extensor lag at the MP, PIP or DIP joints. There is no evidence of a boutonniere, swan-neck, or mallet deformities. There is full composite grip. Wrist and elbow motion are within physiologic range. Impression: - Carpal Tunnel Syndrome - Trigger Finger Management Plan: - Investigations planned: Nerve conduction study - Treatment planned: Wrist splinting, NSAIDs, and referral to occupational therapy - Relevant other actions: Counselling on ergonomic adjustments at work - Work restrictions: Avoid repetitive wrist movements Over 45 minutes were spent in consultation with this patient for both face-to-face and nonface-to-face time by me. Over 50% of the total face-to-face time was spent in counseling and coordination of care. This included review of patient's intake form, obtaining additional history during the encounter, performing a medically appropriate examination based on their symptoms and complaints, subsequently educating and counseling the patient on the condition and recommended treatment, reviewing available results and orders for tests, medications, and procedures, and spending additional time accurately documenting these findings and recommendations within the electronic health record. Dr. Thomas Kelly, M.D. Disclaimer: The dictated information contained herein was transcribed with voice recognition software. Although reviewed, content may contain errors and/or omissions.