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Initial Evaluation

General Information
Pts. Initials: M.D.
Age: 45 y/o
Sex: Female
Address: Solsona
Civil Status: Married
andedness: !"#
$%%u&ation: Cler'
"eligion: "oman Cat(oli%
"e)erring MD: Dr. D
"e)erring *nit: MMM+MC
"e(a, MD: Dr. M
"e(a, *nit: MMM+MC "e(a, *nit
Date o) Consultation: De%. -./ 0112
Date o) "e)erral: De%. -./ 0112
Date o) I3: De%. 01/ 0112
Dx: Car&al 4unnel Syndrome !"# *3
HPI:
Present %ondition started 0 5ee's P4C 5(en Pt ex&erien%ed tingling and a
&ri%'ly &in+li'e sensation into t(e t(um,/ )ore6nger/ middle 6nger/ and (al) o)
t(e ring 6nger 5(i%( usually o%%urs during 5rist movements. S(e also re&orted
t(at a dull a%(ing &ain !PS: 7/-1# extending )rom t(e 5rist t(roug( t(e s(oulder
is ,ot(ering (er es&e%ially at nig(t. Pt ignored (er %ondition t(in'ing t(at it is
only due to &rolonged ty&ing and (ad ta'en )or t(e relie) o) &ain.
8ut a)ter a 5ee'/ t(e Pt noted t(at (er sym&toms are 5orsening due to
t(e o%%urren%e o) num,ness over t(e &alm sur)a%e o) t(e (and/ into t(e t(um,/
)ore6nger/ middle 6nger/ and (al) o) t(e ring 6nger. S(e )urt(er stated t(at s(e
also ex&erien%es di9%ulty in ty&ing/ 5riting/ ,uttoning %lot(es and %lumsiness in
(olding glass in (and. Due to t(is it &rom&ted (er to see' medi%al advi%e to Dr.
D at MMM+MC. S(e under5ent series o) la, exams !see An%illary &ro%edure#
and 5as &res%ri,ed :a&roxen )or &ain relie). S(e 5as t(en diagnosed to (ave
Car&al 4unnel Syndrome on (er !"# (and. 4(en Dr. D re;ered (er to Dr. M at t(e
MMM+MC "e(a, *nit )or t(e management o) t(e sym&toms and re(a,ilitation.
Present Med:
:a&roxen mg ,id )or &ain relie)
PMHx:
!+# Fx
!+# "A/$A
!+# surgery on t(e !"# (and
!+# DM
Ancillary Procedure
<+ray De%em,er 01/ 0112 :o signi6%ant ,ony
a,normality
3M= De%em,er 01/ 0112 !># Fi,rillation and a,normal
re%ruitment &attern o) t(enar
eminen%e
FMHx:
Condition Paternal side Maternal side
DM !+# !>#
"A !+# !+#
$A !+# !+#
PSEHx:
o Sedentary li)estyle
o :on+%igarette smo'er
o :on+al%o(oli% ,everage drin'er
o Pt. lives in a ,ungalo5/ ? t(e (us,and/ - son and a daug(ter
o Pts. room is on -
st
@oor/ ABm )rom %om)ort room/ A4m )rom 'it%(en
and A7m )rom living room
o Pt. 5or's A a minimum o) . (ours a day in a la5 6rm )or a,out C
years no5
o 3%onomi%ally sta,le
S:
%/o: D:amaman(id ang a'ing mga daliri mali,an sa 'ala(ati ng a'ing
&alasinsingan at (inliliit. :a(i(ira&an din a'ong magsulat/ magty&e at
(uma5a' ng ,aso.E
P4 translation: t(e Pt ex&erien%es num,ness on 6ngers ex%e&t t(e lateral (al) o)
t(e ring 6nger and t(e little 6nger. e also ex&erien%es di9%ulty in
5riting/ ty&ing and (olding a glass.
Pt. =oal: 4o ,e a,le to 5or' s di9%ulty.
O:
VS:
8P: -01/.1 mmg
P": CB ,&m
"": -C %&m
4: a)e,rile to tou%(
Findings: FS are G:H
Sig. )or ,aseline &ur&oses
OI/Oservation:
Am,ulatory s assistive devi%e
Mesomor&(
Alert/%o(erent/ %oo&erative
!+# Postural deviation
!># 3ryt(ema
!># In@ammation
!+# S'in lesion !"# 5rist and (and
!+# Atro&(y
Sensory Assessment
S4Ds used: 8rus( )or lig(t tou%(/ t(um, )or &ressure/ &in )or &ain
Findings: -11I inta%t sensation o) !8# *3/H3 as to lig(t tou%(/ &ressure
and &ain
Pal!ation:
:ormot(ermi% on all ex&osed ,ody &arts
!># S5elling
!># =rade I 4enderness on !"# (and
!+# Mus%le s&asm
!+# Mus%le guarding
S!ecial "ests:
!># P(alens 4est
Findings: 4ingling in t(e t(um,/ index/ middle and lateral (al) o) ring
6nger
Sig. &ressure on t(e median nerve indi%ative o) C4S
!># 4inels Sign
Findings: 4ingling in t(e t(um,/ index/ middle and lateral (al) o) ring
6nger
Sig. "egeneration o) sensory 6,ers o) t(e median nerve
#OM:
All maJor Jts. o) !8# *3/H3 are G:H a%tively K &assively done &ain )ree at
end range ex%e&t )or t(e ;:
Lts Motion A%tive Passiv
e
:ormal Di;eren%e
A/P
3nd)eel
!"#
5rist
Flexion
3xtension
"adial
deviation
*lnar
deviation
1+51
1+41
1+-1
1+-5
1+C1
1+71
1+-5
1+05
1+.1
1+C1
1+01
1+B1
01/-1
01/-1
-1/5
-1/5
3m&ty
3m&ty
3m&ty
3m&ty
!"#
t(um,
CMC @exion
CMC
extension
CMC
a,du%tion
CMC
addu%tion
MCP @exion
IP @exion
IP extension
1+-1
1+-5
1+51
51+1
1+41
1+71
1+-1
1+-1
1+-.
1+71
71+1
1+45
1+C1
151
1+-5
1+01
1+C1
C1+1
1+51
1+.1
1+01
5/5
5/B
01/-1
01/-1
-1/5
01/-1
-1/5
3m&ty
3m&ty
3m&ty
3m&ty
3m&ty
3m&ty
3m&ty
Index
6nger
MCP @ex
MCP ext
PIP @ex
DIP @ex
1+C1
1+B1
1+.1
1+C5
1+.1
1+B5
1+21
1+.1
1+21
1+45
1+-11
1+21
01/-1
-5/-1
01/-1
-5/-1
3m&ty
3m&ty
3m&ty
3m&ty
Middle
6nger
MCP Flex
MCP ext
PIP @ex
DIP @ex
1+C1
1+B1
1+.1
1+C5
1+.1
1+B5
1+21
1+.1
1+21
1+45
1+-11
1+21
01/-1
-5/-1
01/-1
-5/-1
3m&ty
3m&ty
3m&ty
3m&ty
"ing
6nger
MCP Flex
MCP ext
PIP @ex
DIP @ex
1+C1
1+B1
1+.1
1+C5
1+.1
1+B5
1+21
1+.1
1+21
1+45
1+-11
1+21
01/-1
-5/-1
01/-1
-5/-1
3m&ty
3m&ty
3m&ty
3m&ty
Findings: Himitation o) motion 0M to &ain
MM":
Mus%le =rade
Grist @exors 4
Grist extensors 4
"adial deviation 4
*lnar deviation 4
4(um, a,du%tor!AP8# 4
4(um, @exor!FP8# 4
$&&onens &olli%is 4
Hateral 0 MCP
@exors!lum,ri%als#
4
:ote: 8rea' test 5as used to assess MM4 at t(e availa,le range o) motion
Findings: All ms. o) !8# *3/H3 are grossly graded 5/5 ex%e&t )or t(e all 5rist
@exors and extensors/ radial and ulnar deviators/ t(um, a,du%tors and @exors/
lateral 0 MCP @exors
Sig:
Gri! Stren$t% "est
Pro%edure: Pt strongly gras&s t(e index and t(e middle 6nger o) t(e
examiner
Hegend: =ood: I) examiner %annot &ull out (is 6ngers
Fair: I) t(e Pt %an gras& t(e 6ngers ,ut examiner %an &ul (is (ands
Poor: I) t(e Pt is una,le to gras& 6ngers totally
Findings: Pt %an gras& t(e 6ngers ,ut P4 %an easily &ull out (er 6ngers
Sig: =ri& is )air 0M to &ain
A&' Analysis:
Patient is inde&endent in all as&e%ts o) ADH su%( as to sel)+%are/ trans)ers/
and ,ed mo,ility ,ut 5it( di9%ulty in ty&ing/ 5riting/ ,uttoning %lot(es and
%lumsiness in (olding glass in (and.
A:
P" Im!ression: 4(e Pt is in t(e a%ute stage o) C4S on t(e !"# (and
#e%a Potential:
4(e Pt (as a good re(a, &otential ,e%ause t(e sym&toms are dete%ted
early on and immediate re(a,ilitation 5ill &revent )urt(er %om&li%ations.
Prolem 'ist:
-# Dull a%(ing &ain !PS: 7/-1# extending )rom t(e 5rist t(roug( t(e s(oulder
0# :um,ness over t(e &alm sur)a%e o) t(e (and/ into t(e t(um,/ )ore6nger/
middle 6nger/ and (al) o) t(e ring 6nger.
B# In@ammation at t(e !"# 5rist
4# S5elling and =rade I 4enderness on !"# (and
5# H$M at t(e !"# lateral B N 6ngers as to t(um, @exion+extension/
a,du%tion+addu%tionO middle and ring 6nger as to @exion+extensionO 5rist
as to @exion+extension and radial+ulnar deviation due to &ain.
7# Mus%le 5ea'ness on all 5rist @exors and extensors/ radial and ulnar
deviators/ t(um, a,du%tors and @exors/ lateral 0 MCP @exors 0M to &ain
C# Minimal di9%ulty in &er)orming ADH su%( as to ty&ing/ 5riting/ ,uttoning
%lot(es and %lumsiness in (olding glass in (and.
.# Fair gri& strengt(
S"G: !B+7 5ee's.#
-# 4o de%rease &ain on t(e !"# (and
0# 4o de%rease s5elling and in@ammation on t(e !"# (and
B# 4o im&rove "$M at t(e !"# lateral B N 6ngers as to t(um, @exion+
extension/ a,du%tion+addu%tionO middle and ring 6nger as to @exion+
extensionO 5rist as to @exion+extension and radial+ulnar deviation
4# 4o im&rove mus%le strengt( on all 5rist @exors and extensors/ radial and
ulnar deviators/ t(um, a,du%tors and @exors/ lateral 0 MCP @exors )rom
good to normal.
5# 4o im&rove gri& strengt( )rom Fair to =ood
'"G: !7+. 5ee's#
-# 4o attain o&timal ADH &er)orman%e as to ty&ing/ 5riting/ ,uttoning %lot(es
and %lumsiness in (olding glass in (and
0# 4o &revent 0M %om&li%ations su%( as %ontra%tures/ atro&(y and 5ea'ness
P: ()*+ "x session/,-.
-# Massage on t(e !"# t(enar mus%les )or ,etter ,lood %ir%ulation
0# Grist s&linting at to avoid re&etitive @exion and rotation
B# 3S !&ro,e# 01 mins on t(e !"# (and
4# SPueeQe ,all exer%ises
5# P"$M and A"$M exer%ise on t(e !"# 5rist
HI:
-# Per)orm t(e exer%ises taug(t ,y t(e P4
0# 3rgonomi%s measure su%( as 5rist su&&ort in ty&ing and t(e use o) anti+
"SIs
B# 3du%ate t(e )amily mem,ers in understanding t(e Pts %ondition

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