amccracken1108
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Please help me in understanding this note...what would you code it as?
CHIEF COMPLAINT: 57-year-old man who presents to us today in consultation from his primary care physician for questions regarding treatment of carpal tunnel syndrome.
HISTORY OF PRESENT ILLNESS: The new patient is a very pleasant right hand-dominant, The patient claims that over the last 15-20 years he has developed progressive numbness and tingling in both of his hands, left worse than right. He actually saw his primary care physician for this and was sent for nerve conduction studies. These were performed and returned with significant compression of both nerves. Those symptoms are worse in the left hand; compression is worse on the right hand. He was sent to us for consultation regarding surgical treatment.
Of significance is the fact that the patient had a ruptured muscle and tendon in the left aim many years ago. He claims he had "nerve damage". He did not have any injury to the median nerve from his description. He attributes the feet that he has worse symptoms in his left hand to his previous injury.
PAST MEDICAL HISTORY:
He has hypertension, arthritis.
REVIEW OF SYMPTOMS: review of systems intake form is reviewed..
MEDICATIONS: Amlodipine besylate, hydrochlorothiazide and daily aspirin.
ALLERGIES: LOTRIL.
PHYSICAL EXAMINATION: Demonstrates a 6 feet 4 inch, 282 pound with a body mass index of 33. His blood pressure is 140/84. He is accompanied today by his wife. The patient is noted to have warm, well perfused hands with 2+ palpable radial pulses bilaterally. Range of motion of the wrist, MP and IP joints is grossly normal. He has a positive Tinel sign over the median nerves in both wrists. He does show some mild flattening of the thenar eminence on the right hand-side though his grip strength is overall excellent. No formal 2-point discrimination tests or grip strengths were performed today.
His nerve conduction studies were reviewed.
ASSESSMENT & PLAN: Carpal Tunnel Syndrome. I discussed my findings with the patient, gave him the recommendation for carpal tunnel release and reviewed all of the studies and my findings with him. We discussed the surgery as performed under a brief general anesthetic using an endoscopic approach first on the left hand which is the more symptomatic and then three weeks later on the right hand. We discussed the expectations for duration of the procedure as well as possible conversion to an open technique. We discussed the time course for healing and resumption of regular activities as well as improvement in symptoms and potential complications including bleeding, infection, unacceptable scarring, damage to the nerve, worsening of hand function, numbness of the palm, recurrent carpal tunnel, pain syndrome and need for further surgery. At this point in time the voices understanding. We will report our findings back to his primary care physician and proceed accordingly.
CHIEF COMPLAINT: 57-year-old man who presents to us today in consultation from his primary care physician for questions regarding treatment of carpal tunnel syndrome.
HISTORY OF PRESENT ILLNESS: The new patient is a very pleasant right hand-dominant, The patient claims that over the last 15-20 years he has developed progressive numbness and tingling in both of his hands, left worse than right. He actually saw his primary care physician for this and was sent for nerve conduction studies. These were performed and returned with significant compression of both nerves. Those symptoms are worse in the left hand; compression is worse on the right hand. He was sent to us for consultation regarding surgical treatment.
Of significance is the fact that the patient had a ruptured muscle and tendon in the left aim many years ago. He claims he had "nerve damage". He did not have any injury to the median nerve from his description. He attributes the feet that he has worse symptoms in his left hand to his previous injury.
PAST MEDICAL HISTORY:
He has hypertension, arthritis.
REVIEW OF SYMPTOMS: review of systems intake form is reviewed..
MEDICATIONS: Amlodipine besylate, hydrochlorothiazide and daily aspirin.
ALLERGIES: LOTRIL.
PHYSICAL EXAMINATION: Demonstrates a 6 feet 4 inch, 282 pound with a body mass index of 33. His blood pressure is 140/84. He is accompanied today by his wife. The patient is noted to have warm, well perfused hands with 2+ palpable radial pulses bilaterally. Range of motion of the wrist, MP and IP joints is grossly normal. He has a positive Tinel sign over the median nerves in both wrists. He does show some mild flattening of the thenar eminence on the right hand-side though his grip strength is overall excellent. No formal 2-point discrimination tests or grip strengths were performed today.
His nerve conduction studies were reviewed.
ASSESSMENT & PLAN: Carpal Tunnel Syndrome. I discussed my findings with the patient, gave him the recommendation for carpal tunnel release and reviewed all of the studies and my findings with him. We discussed the surgery as performed under a brief general anesthetic using an endoscopic approach first on the left hand which is the more symptomatic and then three weeks later on the right hand. We discussed the expectations for duration of the procedure as well as possible conversion to an open technique. We discussed the time course for healing and resumption of regular activities as well as improvement in symptoms and potential complications including bleeding, infection, unacceptable scarring, damage to the nerve, worsening of hand function, numbness of the palm, recurrent carpal tunnel, pain syndrome and need for further surgery. At this point in time the voices understanding. We will report our findings back to his primary care physician and proceed accordingly.
