[doctor] patient shirley taylor . date of birth 5/4/1961 . mrn 0000123 . patient is a 60 year old right-handed female new patient referred by dr. jacob ward for evaluation of bilateral hand numbness and tingling . please note that i personally reviewed the ct brain with and without contrasting did 2/5/21 . uh , no metastatic disease . no acute intercranial abnormalities .
[doctor] hello ms. taylor . how are you doing this morning ?
[patient] hi dr . lopez . this weekend was a bit rough . i've had this numbness and tingling for a few weeks now .
[doctor] so , in both of your hands ?
[patient] yeah . ever since my car wreck last december when i broke them . well , once they heal , i mean , i noticed it more , the , the tingling and numbness .
[doctor] are you still wearing the splint only on your right wrist ?
[patient] no . i wear the left one also sometimes . the right one's just worse . the splint seems to help . both have gotten worse over the last month . when i broke them though , my wrist was definitely in worse shape than it is today . i've been having some mild stiffness in my neck too . i hit my head during the accident , and they told me it was a contusion .
[doctor] okay . and where exactly on the right side would you say the tingling and numbness is ?
[patient] on the right , i can really notice it from my middle and ring finger all the way up to my forearm , and on my left , a bit more the pinky and the ring and not the middle .
[doctor] all right . and , um , is there is pain or , or just tingling and numbness ?
[patient] uh , mainly just sore . sometimes they throb , but overall , they feel weaker too , especially when i'm using them . the tingling happens some more , but when they hurt , you know , it goes away and then the tingling's just dull .
[doctor] what kind of activities ?
[patient] well , really , i guess , just more so at night , and then it just kind of comes and goes throughout the day .
[doctor] okay . and do you experience any loss of sensation in your hands or fingers ?
[patient] uh , like , like feeling something ? no , not that i can think of really . in general , they might be less sensitive than they should be , but i can still feel . they gave me some nerve pain medicine , but i have n't been taking it like i should be .
[doctor] okay . looks like your medical history is notable for chronic kidney disease , gout , hypertension , anxiety , gerd , and diabetes .
[patient] well , i had pre-diabetes , but i got in under control changing my diet .
[doctor] okay . good . and are you still on the carvedilol 25 milligrams two times a day for hypertension and lexapro 10 milligrams a day for anxiety ? looks like your allergic to sulfa drugs as well . is that correct ?
[patient] yeah , i'm still taking those and sulfa just causes me to break out in a rash .
[doctor] and no history of thyroid issues , right ?
[patient] nope .
[doctor] all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain .
[patient] all right . thanks .
[doctor] review of systems , please make the following changes . uh , constitutional , patient reports fatigue and weight gain . gi , um , excessive appetite and bloating . eyes , floaters . uh , cardiovascular , shortness of breath and leg swelling . endocrine , positive diabetes , always hungry . skin , nail bed trenches , dryness , itching . musculoskeletal , gout , muscle pain . neurological , parasthesia , bilateral hands .
[doctor] um , please use the default normal neuro-physical exam with the following changes . sensations normal except pin prick sensation diminished in the third and forth fingers on the right . and the fourth and fifth fingers on the left . reflexes are one plus and symmetric , two plus knees , toes are down going bilaterally , tinel's sign positive at both wrists and both elbows .
[doctor] let's move onto assessment and plan , bilateral carpal tunnel syndrome , question of bilateral cubital tunnel syndrome . i discussed my impression with the patient , i will schedule her for emg , ncv . if her symptoms do not resolve , we can consider hand clinic referral for possible symptomatic injections or carpal tunnel release surgery although she can pursue these uh , through her current orthopedist . i encouraged her to wear her splints , returned for emg , ncv . end of note .

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