Sample Name: Wrist TFCC irritation
Description: The patient has been having problems with the wrist. Right wrist TFCC irritation, possible TFCC tear.
(Medical Transcription Sample Report)
HISTORY: Followup evaluation of his right hand and wrist. He is having wrist pain now. He was having hand pain before. We saw him mostly for just arthritis, and he is seeing a rheumatologist as well. He was getting better with that and then started having some pain in the wrist area. He got an MRI of the right wrist ordered by Dr. XYZ, which showed some sprain of the dorsal and carpal ligament and radial collateral ligament and some abnormality in the TFCC. His pain is on the ulnar side of the wrist. He is tender over the ulnar snuffbox. There is pain with TFCC stress testing although DRUJ is not unstable.
ASSESSMENT: Right wrist TFCC irritation, possible TFCC tear.
The patient has been having problems with the wrist for a while now. I think maybe he will feel better with an injection. He consented to that. After sterile preparation of the right wrist, ulnar side of the wrist is injected with combination of 40 mg Depo and 1 cc of local anesthetic. We are going to see how that works for him. Continue with activity modification. He will follow up with me in a month and just let me know how things are going. Of note on examination, his Jamar grip strength position 2 is 128/135.
Keywords: office notes, wrist, arthritis, tfcc,