Posttraumatic left carpal tunnel syndrome

The patient returns today for reevaluation. She has been receiving “laser treatment” for her left wrist pain and does report some improvement from this. She does continue to have pain to her neck, upper back and low back as well as the left wrist pain. She was having pain shooting into her left upper extremity, which she reports has improved as well. She denies any new complaints at this time.

IMPRESSION:
1. Posttraumatic cervical sprain/strain.
2. Cervical radiculopathy – improved.
3. Posttraumatic thoracic sprain/strain.
4. Posttraumatic lumbar sprain/strain.
5. Lumbar herniated disc.
6. Posttraumatic left carpal tunnel syndrome.

PLAN:
The patient and I have nice talk today regarding her pain and overall plan of care. She is not currently taking any medications and we did discuss the medication options. She has taken anti-inflammatories and muscle relaxants in the past over the past several months. I have given her a prescription for diclofenac 50 mg one pill q.d. We did discuss GI precautions. This was prescribed for anti-inflammatory effects. In addition, she was given a prescription for cyclobenzaprine 10 mg one tablet before bed as needed to help reduce spasm. We discussed that the patient will not drive or operate machinery while taking this medication. The patient will continue with therapy as well as icing and home exercise. We will await approval from her insurance company to do additional trigger point injections. She does have significant trigger points and has had some relief from these in the past. She will call me with any questions or concerns prior to our next visit. We also again discussed that I may send her to see Dr. to discuss interventional procedures as well.

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