Carpal Tunnel Syndrome Case Summary
DOI: 07/27/2006. Patient is a 36-year-old female apprentice engineer who sustained an injury to her neck and back due to lifting of hall demolition debris. Per OMNI entry, she is diagnosed with chronic back sprain/strain.
Urine drug screen obtained on 04/05/16 revealed positive for hydrocodone and Flexeril.
Per the progress report dated 09/06/16, patient complained of low back pain. Her medications are Norco 5/325mg, Motrin 800mg, and Flexeril 7.5mg.
Based on the progress report dated 10/04/16, the patient states that "today the pain is somewhere 4-5 with the help of medication, but patient states that I cannot sleep on my stomach because of the pain."
On examination of the cervical spine, there is slight tenderness at the trapezius on deep
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Tinel’s sign and Finkelstein’s test is positive. There is evidence of carpal tunnel syndrome.
On examination of the lumbar spine, there is slight tenderness at L4-L5 and L5-S1. Heel and toe ambulation could not be conducted because of instability and pain. Range of motion (ROM) shows bilateral lateral flexion at 30 degrees and bilateral lateral rotation at 40
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Knee and ankle jerks are 1+, bilaterally. There is weakness of the quadriceps, hamstrings as well as the flexors and extensors of the hips.
Assessments include cervical sprain, lumbar sprain, constipation, left carpal tunnel syndrome, lumbar degenerative disc disease, and retrolisthesis at L5-S1. Patient was given prescription for Norco 5/325 mg one tablet twice daily for severe pain #60, Motrin 800 mg 1 tablet twice daily as needed for inflammation and pain #60 and Flexeril 7.5 mg 1 tablet at bedtime for muscle relaxation #30.
Requested from the provider’s office copies of recent urine d rug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no reports were received prior to the submission of this request to PA.
Patient has been previously certified with 45 Tablets of Norco 5/325 mg and denied with 60 Tablets of Motrin 800 mg and 30 Capsules of Flexeril 7.5 mg on 09/13/16 ( Review 275436).
Current request is for 30 Tablets of Flexeril 7.5 mg; 60 Tablets of Norco 5/325 mg; and 60 Tablets of Motrin 800 mg between 10/11/2016 and
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