Left Wrist Case Summary

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DOI: 7/28/2014. Patient is a 33-year old male laborer who sustained injury when his left wrist twisted and snapped while using a drill. Per OMNI, he was initially diagnosed with dislocation of the left wrist. He underwent a tendon graft reconstruction on 08/07/14 and hardware removal on 09/11/14.
Based on medical report dated 06/12/15, the patient reports that his left wrist is hurting significantly. He presents with pain and dysfunction of the left wrist. The patient continues to experience substantial discomfort, is frustrated by lack of progress.
On examination, the wrist shows radiocarpal joint swelling, with decreased range of motion. Flexion-extension is restricted, but pronosupination is full. Digital motion is without significant restriction.
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He continues to struggle, despite continuing to work. He was provided with 1 cc of Celestone and 1% lidocaine over his radiocarpal joint, which moderately improved his symptoms.
As of this report, X-rays show no sgnificant radiocarpal joint narrowing, but does show scaphoid diastases, unchanged comparison to previous exams on the anteroposterior lateral oblique left wrist films.
He was diagnosed with wrist pain. Plan is for a left wrist scaphoid excision, 4 corner fusion. This will require use of the Stryker EasyClip staples.
He is currently taking Ibuprofen 800 mg 1 tablet 3 times a day.

Per OMNI payment screen, the patient has completed approximately 17 PT sessions to the left wrist from 10/03/14 through

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