History of present illness: Patient is a 36 year old female with a chief complain of tingling and numbness in her first 3 fingers and thumb of both wrists, mild burning sensations heading proximally in her right arm, trouble grasping objects, and having issues making a fist. The patient has been working as a secretary for the last 10 years. Past medical history Herniated disc between C6-C7. Family history: Moher died of bladder cancer and father has coronary artery disease. Social History Social alcohol usage (a glass of wine every one-two weeks) with friends and family. No Tabaco or recreational drug history. Allergies None Medications Ibuprofen 400 mg when needed. Birth control pill Key Labs, images, or procedures performed in relation to current diagnosis. Nerve conduction study: Median nerve impulse were slower than normal Tinel’s test: Positive. Phalen’s test: Positive Key Physical Examination findings: Tenderness when the wrist was overextended. 5. Provide treatment 6. Provide the prognosis for the diagnosis at hand
History of present illness:
Patient is a 36 year old female with a chief complain of tingling and numbness in her first 3 fingers and thumb of both wrists, mild burning sensations heading proximally in her right arm, trouble grasping objects, and having issues making a fist. The patient has been working as a secretary for the last 10 years.
Past medical history
Herniated disc between C6-C7.
Family history:
Moher died of bladder cancer and father has coronary artery disease.
Social History
Social alcohol usage (a glass of wine every one-two weeks) with friends and family.
No Tabaco or recreational drug history.
Allergies
None
Medications
Ibuprofen 400 mg when needed.
Birth control pill
Key Labs, images, or procedures performed in relation to current diagnosis.
Nerve conduction study: Median nerve impulse were slower than normal
Tinel’s test: Positive.
Phalen’s test: Positive
Key Physical Examination findings:
Tenderness when the wrist was overextended.
5. Provide treatment
6. Provide the prognosis for the diagnosis at hand
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