Per the occupational therapy progress report dated 11/19/15, the patient has attended 7 sessions. Patient reported some progress, but complains of burning to the thumb and forearm with any soft tissue massage.
Per the QME report dated 06/02/16, it was noted that relative to the IW’s complaints of numbness and tingling, although improving with the use of a wrist splint, electrodiagnostic studies should be performed.
Electrodiagnostic studies performed on 08/04/16 were consistent with bilateral carpal tunnel syndrome, …show more content…
Garay, the patient describes numbness and tingling in the thumb, index, and long fingers of both hands. She awakens at night with symptoms. It appears that right sided symptoms are worse than the left.
On examination of the bilateral wrists, Phalen and Tinel signs are positive in the median nerve distribution of the carpal canal, right greater than left. Jamar grip strength measurements are 18/16/12 kg on the right and 16/16/16 kg on the left.
IW was diagnosed with status post right thumb A1 pulley stenosing tendovaginotomy,10/12/2015, resolved and bilateral carpal tunnel syndrome, right greater than left.
Recommendation was made for a right carpal tunnel release followed by left sided carpal tunnel release. The patient would like to proceed.
Requested verification from the provider’s office if the IW has had a steroid injection; however, no callback was received by the time this case is forwarded to PA for review.
Current request is for 1 Right Carpal Tunnel Release; and 8 Post-Operative Occupational Therapy Visits of the Right Hand between 9/16/2016 and