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
