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

Human Anatomy & Physiology (11th Edition)
11th Edition
ISBN:9780134580999
Author:Elaine N. Marieb, Katja N. Hoehn
Publisher:Elaine N. Marieb, Katja N. Hoehn
Chapter1: The Human Body: An Orientation
Section: Chapter Questions
Problem 1RQ: The correct sequence of levels forming the structural hierarchy is A. (a) organ, organ system,...
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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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