NU 685 SOAP Note II

Soap Note # 2

Date of Exam: 2/7/2023

Source of History: Patient is the primary source of information and is a reliable historian

(Subjective)

Chief Complaint: “I have pain in my right hand.”

HPI: Patient is a 50 y/o African American female, medical biller, who reports she has been experiencing numbness and pain intermittently for 1 month in the right hand. Pain is worsening now x 2 days. Reports 8/10 pain most of the time, on a pain scale of 0/10. Pain is worse while at work and at night. Pt states she has been icing and massaging the hand with some relief but the pain keeps coming back. Patient reports she was not able to work the past two days and denies taken pain medication. No discomfort of pain or numbness at this time.

PMH: HTN, Hyperlipemia

PSX: Tonsillectomy-9 y/o

Medication:

Metoprolol 100mg p.o daily

Atorvastatin 20mg p.o daily

Allergies: Denies

FHX: Father, alive 77 HTN, DM, prostate cancer

Mother, alive 79 y/o DM

Vaccine Flu vac 10/2022, Coved booster 11/2022

Social Hx:

Denies smoking

Denies alcohol

Illicit drugs

Patient lives with significant other, have 1 child 18 y/o male

Review of Systems

General: Patient denies fatigue and fevers, denies weight gain or loss, within the pass 3 months. No night chills or weight changes. Sleeps 8 hrs. per night

HEENT

Head: Denies head injuries, headaches, or dizziness

Eyes: Denies corrective lenses, last eye exam 4/4/22, no pain, redness, or excessive tearing, no double or blurry vision

Ears: Denies hearing loss, tinnitus, vertigo, or ear ache

Nose: Denies recent cold congestion

Neck/Sinus: Denies lump, pain, and stiffness or swelling

Breast: Denies lumps, discharge, or discomfort in breast

Respiratory: Patient denies shortness of breath, orthopnea, asthma or bronchitis, coughing, wheezing, pain on respiration, or pneumonia last TB test was 3/18/22 (-)

Cardio: Patient denies chest pain, palpitations, angina pectoris, murmurs, rheumatic fevers, heart disease, paroxysmal nocturnal dyspnea, venous thrombosis, dizziness, diaphoresis. Last EKG 6/3/22

MS: Denies back ache, stiffness, edema, ulcer, heat, redness, deformity, myalgia, weakness, bone fractures, arthritis, admits numbness, limited range of motion to right wrist

Psych: Denies wanting to harm self or others, depression, memory loss, nightmares or phobias

Objective / Physical Exam

VS: BP 152/80 (sitting) HR 88 RR 20 O2 SAT 98% (on RA) Temp 98.4 (oral) BMI 26

General: Patient is a well-nourished African American female. Patient is alert and oriented x4. Speech is clear and patient is dressed appropriately for the season. Answers congruent with questions. Patient walked in with steady gait and sitting upright.

HEENT

Head: Normocephalic, no lesions

Eyes: PERRLA, EOM’s, full conjunctiva, clear fundi, grossly normal

Ears: EAC’s clear, TM’s normal

Nose: Mucosa normal, no obstruction

Neck/Sinus: Clear, no exudate, no lesions

Respiratory: Lungs clear to auscultation and percussion, breath sounds equal throughout

Cardio: S1, S2 noted, no lift, no hives, no thrills, no murmurs, no rubs, no gallops or clicks.

Peripheral pulses intact, 2+ equal throughout

MS: Full range of motion, symmetric strength, and normal muscle tone, no atrophy, Phalen’s and Tinel’s test positive to right hand

Assessment/ Diagnostic

Labs: CBC, CMP, EKG, ultrasound of the right hand and right hand x-ray

Differential diagnosis

Rheumatoid Arthritis

– RA is a progressive, inflammatory, and erosive condition that usually effects multiple joints. In addition to the articular changes associated with RA, there is a range of systemic effects. RA is an autoimmune condition. RA typically affects the joints symmetrically.

Osteoarthritis OA is another common cause of polyarthralgia. This progressive disorder is associated with age and with wear and tear. OA causes a loss of cartilage and progressive erosion of bone.

Carpal Tunnel Syndrome

The carpal tunnel is a place located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons traverse. With overuse and repetitive movements, the various tissues my hypertrophy, causing a loss of space and impingement on the median nerve. the type of activities associated with carpal tunnel syndrome include computer use and painting.

Most likely diagnosed/Carpal Tunnel Syndrome

Plan

Continue with life style changes, diet and exercise

Ice pack to right wrist area

X- Ray of right hand

Ultrasound of the right hand

Ibuprofen 400 mg p.o Q 4 hrs. PRN for pain and inflammation (take with food)

Right wrist splint to wear during the day

Referral: Orthopedic

Return to the office in 7 days for follow up