Occupational Therapy: Case Summary

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DOI: 10/30/2015. Patient is a 50-year-old right hand dominant female system analyst who sustained injury due to repetitive use of computer keyboard and tasks. Per OMNI, she was initially diagnosed with strain to the hands and elbows.
Per the progress report dated 01/20/2016, she underwent a corticosteroid injection in her elbow region. She indicated she also received multiple injections in her thumb region and wrist region.

Per the progress report dated 02/10/16, the patient has attended 12/12 occupational therapy sessions and has undergone 2/6 acupuncture treatments for her bilateral epicondylitis. She continues to use her left wrist brace and right thumb spica splint. She continues to use ibuprofen. She has had multiple trigger …show more content…
Garay, the patient’s complaints are confined to both elbows in the medial and lateral epicondylar region, bilateral wrists in de Quervain radial styloid region, and bilateral thumb triggering, which causes her a fair amount of discomfort.
The patient was initially treated with nonsteroidal antiinflammatory medication, a Count’R Force brace, and modified duty. On 12/01/2015, recommendation was made for a course of occupational therapy.
Medical history includes Hashimoto’s disease; a bleeding disorder, and diabetes mellitus.
On examination of the bilateral upper extremities, the bilateral shoulders have full range of motion. Bilateral elbow range of motion is 0-130 degrees. Bilateral wrist dorsiflexion is 65 degrees and palmar flexion 65 degrees. There is full range of motion of the fingers and thumbs. She is able to make a complete fist and touch the fingers to the midpalmar crease and touch the tip of the thumb to the fifth metacarpal. Bilateral elbows reveal tenderness to palpation of both the medial and lateral epicondylar …show more content…
The patient is a candidate for surgical decompression. She failed a course of conservative management to include activity modification, nonsteroidal anti-inflammatory medications, occupational therapy, and corticosteroid injections. The surgery recommended at this time is for the left upper extremity, the most symptomatic side. This would consist of left elbow medial and lateral epicondylectomy with release of flexor pronator mass, and the origin of the extensor carpi radialis brevis. In addition, a first dorsal extensor compartment release and A1 pulley release of the thumb would be carried out at the same sitting. The patient would then undergo right upper extremity surgery at a later
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