SOAP

Pt Initials: WL

Pt Encounter No.

Date: 10/05/20

Age: 59

Sex: F

Allergies: Denies

Advanced Directives: Full Code

“I have numbness on my right index and middle fingers.”

Patient is 59 -year-old female with no PMHx comes to the clinic today c/o numbness to the right index and middle fingers for the past 2 months. Patient reports right wrist fracture two years ago. Patient states it is usually a feeling of "pins and needles" sensation, the symptoms often appear with some activities like while holding a steering wheel, phone or newspaper, and she is complaining of wake up from sleep so frequent and she need to "shake out" their hands to try to relieve their symptoms.

Onset: two months ago

Location: right index and middle fingers

Duration: intermittent

Characteristics: sharp

Aggravating Factors: extensive hand work

Relieving Factors: rest

Treatment: None

Current Medications:

B-Complex Tablets

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: Denies

Screening Hx/Immunizations Hx: Up to date. Refused Influenza Vaccine last year. Mammography (None). Pap smear (2018) normal results. Colonoscopy (at age 50) normal results.

Hospitalizations/Surgeries: Appendectomy.

Family History

Father- 91 years old alive, HTN and CHF.

Mother-86 years old died from hemorrhagic stroke

Social History

General

Denies chills, night sweats, fatigue, or recent weight changes.

Cardiovascular

Denies palpitations, claudication, chest pain, or orthopnea.

Skin

Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, no jaundice.

Respiratory

Denies painful breathing, SOB, abnormal sputum production, cough. Denies recall taking a TB skin test,

Eyes

Denies visual loss, double vision, or blurred vision. Patient states has no history or cataracts or glaucoma.

GI

Patient denies abdominal pain, difficulty swallowing, vomiting, intolerance to food, appetite changes, or stool changes.

Ears

Denies ear pain, ear infections, or tinnitus. Denies hearing loss.

GU/ Gynecological

Patient denies urinary urgency, frequency, dysuria, odorous urine and suprapubic pain. Patient reports voiding at 0900AM

LMP: 10 years ago

Nose/ Mouth/ Throat

Denies nasal pain or discharge, congestion, or other sinus problem. Refutes throat swelling or pain.

Musculoskeletal

Denies limits to ROM, swelling, muscle pain, or warm joints. Occasional right wrist pain.

Breast

Denies discharge, redness, tenderness or any other breast changes. No palpable mass during self-exam.

Neurological

Patient denies rebuts coordination difficulties, paralysis, tremors, seizures, or syncope. Intermittent numbness of the right index and middle fingers.

Hemo/ Lymph/ Endo

Foregone

Psychiatric

Denies problems with coordination, nervousness, feelings of irritability, mood changes, anxiety, or depressive symptoms.

Weight: 84kg

Height: 5’6’’

BMI: 29.9

Temp: 97.7

BP: 120/80

Pulse: 80

Resp: 16

Pulse Ox: 100%

General Appearance

Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed. Pain level: 0/10. Normal general appearance. Patient is awake, oriented, and alert. Well-developed and nourished. Patient keeps a normal position and posture without deformities. Patient speaks clear and appropriate in native language. Excellent personal hygiene. No acute distress.

Skin

Skin warm, wnl color and moist. Normal skin turgor. No lesions, redness, swelling or cyanosis noticed. Capillary refill less than 3 sec.

HEENT

Head Normocephalic with normal hair distribution. No facial swelling noted. Eyes: PERRLA;

EOMI. Fundi benign. Ears: TMs intact with no erythema; Nose: Mucous membranes pink and moist. Nasopharynx without erythema, exudates, or lesions; Mouth: good dentition, no missing teeth, tongue in normal position, Gag Reflex intact.

Cardiovascular

S1 and S2 normal without MRG. No extra murmurs or sound present. No carotid bruits. No JVD.

Respiratory

Symmetric chest wall. Respirations even and unlabored; lungs clear to auscultation bilaterally. No fremitus.

Gastrointestinal

Abdomen soft, no tenderness, no masses, Bowel sounds presents and normal in the four quadrants. No abnormal aortic pulsations. No ascites. No splenomegaly, no hepatomegaly, nor hernia. No muscle rigidity. No rebound, no guarding. No painful to palpation.

Breast

No nipple retraction, lymphadenopathy, or nipple discharge. No changes in the breast area skin.

Genitourinary

No inguinal hernias or CVA tenderness.

Musculoskeletal

ROM WNL without crepitus or pain except in Left Upper Arm ROM limited due to pain

Neurological

Patient AAOX4. Speech clear and coherent. Cranial nerves I-XII intact. Motor and sensory levels intact. Tinel’s Sign and Phalen’s Maneuver positive.

Psychiatric

Patient appears to have normal affect and is able to follow commands. No signs of anxiety or depression noticed.

Labs Tests

None

Special Tests

Cervical X-ray

Right hand X-ray

Nerve Conduction Velocity Test, Electromyogram

Diagnosis

Carpal Tunnel Syndrome (ICD 10 G56.01).

Differential Diagnosis

· Cervical Radiculopathy

· Brachial plexopathies

· Posttraumatic Medial Nerve Damage

Pharmacological treatment:

• Ibuprofen 800mg po bd.

• Gabapentin 100 mg po tid

Non-Pharmacologic treatment:

• Wrist splint

Teaching

· The patient was instructed in carpal tunnel syndrome to avoid activities that increase stress on inflamed tissues, grasping and gripping action of hand and wrist, to keep the wrist in neutral position, to avoid the wrist in a bent flexed, twisted, turned position, and to minimize repetitive movements, including holding an object for extended periods of time.

· The patient was advised to wear a wrist splint to help keep the wrist in neutral position.

· The patient was taught on range-of-motion exercises and their importance for strengths of muscles.

References

1. Alcan, V., Zinnuroğlu, M., Karataş, G. K., & Bodofsky, E. (2018). Comparison of Interpolation Methods in the Diagnosis of Carpal Tunnel Syndrome. Balkan Medical Journal, 35(5), 378–383. https://doi.org/10.4274/balkanmedj.2017.1314.

2. 2-Durham, C. O., & VanRavenstein, K. (2017). It’s All in the Wrist: Diagnosis and Management of Carpal Tunnel Syndrome. Orthopaedic Nursing, 36(5), 323–329. https://doi.org/10.1097/NOR.0000000000000390.

3. 3-Fernández, de‐las‐Peñas, C., de, la‐Llave‐Rincón, A. I., Cescon, C., Barbero, M., Arias, B. J. L., & Falla, D. (2019). Influence of Clinical, Psychological, and Psychophysical Variables on Long‐term Treatment Outcomes in Carpal Tunnel Syndrome: Evidence from a Randomized Clinical Trial. Pain Practice, 19(6), 644–655. https://doi.org/10.1111/papr.12788.

4. Publication Manual of the American Psychological Association, 6th Edition (2009)

5. Dr. Allan H. Goroll MD MACP; Dr. Albert G. Mulley Jr. MD MPP. (2014). Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 7th Ed.

6. Lucille A. Joel EdD APN FAAN. (2017). Advanced Practice Nursing: Essentials for Role Development.