[doctor] patient mrn : abc123 . date of birth : january 1st , 1960 . patient is a 60 year old , right-handed male , referred today for evaluation of numbness and tingling .
[doctor] hello , mr. cook . how are you doing this morning ?
[patient] hi , dr. martinez . this weekend was a bit rough . i've had this numbness and tingling for a few weeks now .
[doctor] so it's in both of your hands ?
[patient] yes , ever since my car wreck last december when i broke them ... well , once they healed , i mean , i noticed it more , the tingling and the numbness .
[doctor] and you still wear the splint only on the right wrist ?
[patient] no , i also wear the left sometimes . the right is just worse , but the splint helps . both have really gotten worse over the last month . when i broke them , my right wrist was definitely in worse shape . i've also been having some s- mild stiffness in my neck too . i hit my head during the accident , and they told me it was a contusion .
[doctor] and where would you say the tingling and numbness is ?
[patient] on this side , it goes from here and here up to about here . on the other side , it's from here to here .
[doctor] i see . so on the right side , you're pointing from the middle and ring finger , all the way up the forearm . and on the left , the symptoms extend from the pinky and ring finger . and is there any pain or just tingling and numbness ?
[patient] eh , it's mainly just sore . sometimes they throb , but overall , they feel weaker too , especially when i'm using them . the tingling happens more when they hurt , but when it goes away , the tingling is dull .
[doctor] and when do you feel these symptoms ?
[patient] well , really , i guess , just more so at night , and they come and go throughout the day .
[doctor] okay . and do you experience any loss of sensation in your hands or fingers ?
[patient] like , feeling something ? no , not that i can really think of . though , in general , they may be less sensitive than they should be , but i can still feel . they also gave me some nerve pain medicine , but i have n't been taking it like i should .
[doctor] and are you still on the coreg for hypertension and the lexapro for anxiety ?
[patient] yes , i'm still taking those . i had prediabetes too , but i got it under control by changing my diet .
[doctor] and no history of thyroid issues , correct ?
[patient] nope .
[doctor] all right , thank you , mr. cook . okay , first , we'll go over your review of systems . correct me if i'm wrong in any of this .
[doctor] constitutional , you have fatigue and weight gain ; gi , you have excessive appetite and bloating ; eyes have floaters ; cardiovascular shows shortness of breath and leg swelling ; endocrine , you're always hungry ; skin , you have some nail bed changes , dryness , itching ; musculoskeletal , you have gout and muscle pain . and the remainder of the review of systems is negative .
[patient] yep , that's all correct .
[doctor] all right , we're going to go ahead and do the neurologic examination . let's look at the right hand first . can you feel this ?
[patient] yeah , but a little less on these two fingers .
[doctor] sensation is normal , except pin prick sensation diminished in third and fourth fingers on the right .
[doctor] and how about on the left ?
[patient] um , yeah , but these two a little less .
[doctor] sensation is decreased in the fourth and fifth fingers on the left
[doctor] okay , let's test your reflexes now . reflexes are 1+ and symmetric ; 2+ knees ; toes are downgoing bilaterally .
[doctor] all right , i'm going to tap on your right wrist . do you feel anything ?
[patient] yeah , it feels like a zing up my wrist and something into my elbow too .
[doctor] and how about the left side ?
[patient] yeah , same on that side too .
[doctor] tinel sign positive at both wrists and both elbows . rest of exam is normal .
[doctor] all right , so what i am seeing today is bilateral carpal tunnel syndrome or , potentially , this could also be bilateral cubital tunnel syndrome . however , your symptom presentation suggests car- bilateral carpal syndrome , as the nerve in your wrists are aggravated by your past trauma . this is causing the pain and tingling you were describing to me .
[patient] okay , so how do we make it better ?
[doctor] first , i want to determine exactly where the nerve irritation is coming from . we'll need to schedule you for a nerve test , which is called an emg test . they will measure the responsiveness of your nerves to truly pinpoint where you are having your issues .
[patient] that sounds fine to me .
[doctor] great . after the tests are complete , you can return here for a follow-up visit . if you're still having symptoms , we can consider a referral to our hand clinic , possibly for injections or carpal tunnel release se- surgery . you could also refer ... we could also refer you to an orthopedist for the same treatment .
[patient] sounds good , doc .
[doctor] all right , keep wearing your splints , and i will see you after those studies .
[patient] thank you .

Medical orders:
description: follow-up
order_type: followup