Carpal Tunnel Case Study

DOI: 12/17/2011. Patient is a 52-year-old male pasteurizer machine operator who sustained injury when he slipped and fell while climbing up the ladder. Per OMNI, the patient has undergone right carpal tunnel release and decomp0ression on 11/06/15, epidural steroid injection, gastro endoscopy and left knee surgery.

Per the AME report dated 6/2/15 stated that future medical care includes orthopedic consultations for exacerbation, as well as short courses of physical therapy and/or prescription medication. Repeat surgery should be left open for the right wrist, as well as the possibility of surgical intervention for the bilateral shoulders and bilateral knees.
Per PT notes dated 12/18/15, the IW ah s attended 4 sessions for the right wrist

Current medications are Oxycodone, Lyrica, Naproxen, and Miralax. Physical examination of the upper extremities reveals well-healed scar over the right wrist from previous carpal tunnel. There is a positive Tinel’s in the left wrist. The patient has completed 12 acupuncture treatments with improvement of muscle spasm.
Based on the progress report dated 02/16/16 by Dr. Rottermann, the patient has weakness and pain on his right wrist. No therapy has been authorized. He is very depressed and needs to be seen by a psychiatrist. MD would like to request for a second opinion for knee replacement. He reports that his neck and shoulders are worse.
On examination, there is pain and tenderness of the neck and lumbar spine. There is limitation of movement of his shoulder. There is weakness with gripping. There is cracking and crepitation on his knees.
There are scars on his hand. The patient has a cane and knee/wrist braces. He is ambulating slowly.
Diagnoses include bilateral knee osteoarthritis, cervical/lumbar strain, bilateral carpal tunnel syndrome, status post carpal tunnel releases, depression and sleeping