Hand Plastic Surgery Consultation Note - CTS/Dupy/trigger

OVERALL_INSTRUCTIONS

Chief Complaint

Plastic Surgery Consultation Note - carpal Tunnel Syndrome

Template

Thank you for your referral of [name] for Plastic Surgery Consultation. [pronoun] was seen on [date]. (if appointment is telehealth can we say above patient had a telehealth appointment rather than patient was examined) [Provide a detailed narrative of the patient's current condition, including symptoms, onset, duration, and any relevant history. Include any prior diagnoses, treatments, or interventions related to the current condition. Mention any exacerbating or alleviating factors and the impact on the patient's daily life.] For example: [name], a [age]-year-old [handedness] [gender], presents with [primary_symptom(s)]. [Provide details about the symptom(s), including history, associated conditions, and any treatments tried.] Past Medical History: (include as relevant) [List the patient's past medical conditions.] For example: - [condition_1] - [condition_2] Past Surgical History: (include as relevant) For example: - [surgery_1] - [surgery_2] Social History: (include if relevant) [Provide details about the patient's social history, including smoking status, occupation, and other relevant lifestyle factors if discussed in the conversation, omit section if not discussed.] Allergies: [list allergies or if none then state None if not mentioned moit this section] Current Medications: [List the patient's current medications, including dosages and purposes if known. Include if discussed in the conversation, omit section if not discussed.] For example: - [medication_1] for [condition] - [medication_2] for [condition] Nerve Conduction Studies: (only put this heading in if the consutl is for carpal tunnel syndrome or other nerv compression problem, do not put this heading in for trigger finger or dupuytrens consults) [summarize nerve conduction study results or if not done comment if they have been requested] Imaging: [if any xrays, ct scna or MRI tests metioned please list here otherwise leave this heading out] Lab Work: [if any lab work results mentioned or planned please mention hear otherwise leave this heading out] Physical Examination: [Document the findings from the physical examination, including any abnormalities or notable observations.] (For example: Upon examination, there is some thenar atrophy on the left side of [pronoun] hand, with muscle loss noted. The right side appears normal. [pronoun] has a scar on [pronoun] right thumb from a previous tendon repair. The APB strength is rated [number] out of [number] on the left side. Tinel's sign is positive on the left side and negative on the right side. Durkan's compression test is positive on both sides.) Assessment: [Provide a summary of the patient's condition(s) based on the examination and history.] For example: - [condition_1] - [condition_2] Plan: [Outline the management plan for the patient, including monitoring, treatments, follow-up appointments, and any other recommendations.] Surgical Discussion: [Provide a detailed discussion of the proposed surgery, including the purpose, risks, anesthesia, alternatives, recovery, follow-up care, and expected outcomes. Include items that are discussed in the conversation, omit if not discussed] If the diagnosis is dupuytresn can use this for postop insturction basis We have discussed the various options including needle release, collagenase injection, and palmar fasciectomy. We discussed the generally quicker recovery but higher recurrence rate of a needle release. We discussed the risk of nerve or flexor tendon injury, wound infection, wound healing problems and reflex sympathetic dystrophy. With respect to a palmar fasciectomy we discussed the risks and complications including wound infection and wound healing problems nerve injury reflex sympathetic dystrophy and the lower recurrence rate compared to the other techniques. For example - I have gone through the risks and complications of a carpal tunnel release, explaining that this would be done through a 1.5 to 2cm incision in the palm under local anesthetic. The risks of wound infection and wound healing were discussed. The rare but significant risk of nerve injury was discussed. In addition, we talked about the possibility of ongoing pain post operatively or a complex regional pain syndrome, as well as the prolonged nature of recovery from this. The possibilities of symptoms not improving or incomplete release were also discussed. Post operative tenderness in the scar that would typically last in the 4-6 week range, but sometimes can be significantly longer, were also discussed.ab do not put my email on these notes