GENERAL INFORMATION:

Pxs Initial: I. A. C.
Age: 41
Sex: Male
Address: Kawit, Cavite
Civil Status: Married
Handedness: (R)
Occupation: Call center agent chat support team
Nationality: Filipino
Referring Unit: ZARS Hospital
Referring MD: Dr. A
Rehab Unit: ZARS Rehab Unit
Rehab MD: Dr. P
Date of Consultation: May 27, 2016
Date of Referral: June 16, 2015
Date of IE: May 30, 1016
Informant/Reliability: Px/Good
Type of Patient: Out-Px
Dx: CTS 2 to R Preisers dse, L Kienbocks dse

HPI:
Present condition started last July 19, 2015, ~1 yr ago, when the px felt
throbbing pain on his R dorsoradial aspect of hand PS 5/10. The pain lasted for
hours, so the px started stretching and shaking his R hands.
The same case happens everyday, the px continuous shaking and stretching
of his hands and the px started taking pain relievers(see meds) ~6wks PTIE. The
pain increased from PS 5/108/10 and still the px feels numbness.

~5wks PTIE, the px begins to wake up every morning c numbness in his R

hand and FA. And the nagging pain on his dorsoradial aspect of hand worsened at
work fr PS 7/109/10. The px is now experiencinga significant grip weakening. But
the px continues his meds. By this time, most of his work where shifted from his R
hand to his L.
~3wks PTIE, the px feels a gradual deep localized pain on his L hands PS 6/10
when the px is typing. The px also experiences weakening on his grip strength. The
px also felt tenderness on his left hand. Most of his ADLs were affected.
~2wks PTIE, d/t his meds intake the pain felt by the px on his L hand were
also decreased fr PS 6/103/10. Bbut still theres tenderness on his L hand and
numbness on his R hanad every morning and worsens at work. This causes the px
to have a check-up and x-ray.
Nagging pain on his R dorsoradial hand and deep localized pain on his L hand
became significant PS 9/10 c presence of numbness and tenderness. The px got the
result of his x-ray the next day after he checked-up and was dx to have L
kienbocks dse and CTS d/t R Preisers dse. Nagtiis muna ang px aat hnintay and
sweldo bago magpa-PT rehab. Kaya ininda muna niya ang sakit for~2wks
At present, the px went to the rehab to undergo PT eval. Px still complains of
deep, localized pain PS 8/10 and a tingling sensation on her both hands, also has
the presence of tenderness on her palmar region. Px is independent c
maximaldifficukty in doing adls such as typing, UE dressing, hygiene and eating
ANCILLARY PROCEDURE:

X ray on R
and L wrist

Date

MD

Findings

Significance

May 27,
2016

Dr. A

Sclerosis and
fragmentation of
proximal pole s evidence
of fx

CTS d/t Preisers

dse on R wrist
and Kienbocks
dse on L wrist

Medications: administered orally

Acetaminophen

PMHx:
(-) Hospitalization

Dosage

Significance

4000 mg/day

Pain reliever

(-) Htn
(-) trauma
(-) DM

FMHx:
Maternal

Paternal

Htn

(-)

(-)

DM

(-)

(-)

Arthritis

(-)

(-)

PSEHx:

Type B personality
Call center agent chat support team (job started when px as 30 y/o; for ~ 10
years; works 3-5 hrs a day)
Non cigarette smoker
Non-alcohol drinker
Caffeine drinker
Hobbies: writing and typing
Financially stable
Px bedroom located on the 2nd floor; door knob: lever handle

S:
C/C: Nahihirapan ako igalaw ung kamay.

PT Translation: Px c/o LOM on R and L hand d/t pain

Pxs Goal: Gusto kong bumalik sa dati yung lakas at makapagtype at makagawa
ng mga gawaing bahay muli ng maayos na walang iniindang sakit o kung ano man.
Sa lalong madaling panahon.