Radiculopathy of his right upper extremity, particularly in the distribution of the ulnar nerve.

The patient is a 39-year-old white male who complains of right ulnar distribution paresthesias for one-week duration. The patient is otherwise healthy appearing 39-year-old guitar playing male who complains of one-week of pins and needle sensation in the distribution of his right median nerve. He is a right-handed gentleman, plays a guitar and states he has a concert in two week. He is hoping for a treatment that will help his numbness in his right hand as soon as possible. The patient currently takes Motrin 600 mg p.r.n., had been on Neurontin 100 mg a day, but he states that he went off of it because it caused him to feel loopy that he did not have pain, just numbness. He has no other injuries and no other complaints.

PAST MEDICAL HISTORY:
He has seasonal allergies.

PAST SURGICAL HISTORY:
Include surgery for stomach abscess in the distant past.

SOCIAL HISTORY:
He drinks alcohol moderately. He does not smoke. He could not answer if he uses recreational drugs. Occupation, he is guitarist. He is married and has one child. Education level is some college education.

ASSESSMENT:
This patient has radiculopathy of his right upper extremity, particularly in the distribution of the ulnar nerve.

RECOMMENDATIONS:
The plan is to do physical therapy this week focussing on his right upper extremity. If in fact his numbness does not disappear, he will call the office and we will do a neuropathy workup. The patient understands the plan and agrees with that and will follow up with me on an as needed basis.

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