Episodic/Focused SOAP Note Right Wrist Pain and Numbness

Episodic/Focused SOAP Note Right Wrist Pain and Numbness

Episodic/Focused SOAP Note Right Wrist Pain and Numbness

Patient Information:

Initials: L.R.

Age: 47

Sex: female

Race:

Episodic/Focused SOAP Note Right Wrist Pain and Numbness

Subjective. Episodic/Focused SOAP Note Right Wrist Pain and Numbness 

CC (chief complaint): aching right wrist pain; tingling sensation and numbness on the right thumb, index finger, and middle finger.

HPI: a 47-year-old female presented to the clinic complaining of right wrist pain and numbness & tingling in the thumb, index, and middle fingers. This has made her anxious because she drops her hairstyling tools unknowingly. The wrist pain is aching in character and started gradually two weeks ago and is now associated with numbness and tingling. Initially, the pain was relieved by shaking the right hand, but she occasionally used over-the-counter Tylenol to ease the pain in the last few days. The pain is aggravated by pressure on the right wrist, and when she uses the same hand to perform daily life activities. She rated the pain 5/10. There is no history of trauma to the right wrist. She also reports no visible swelling but stated that she feels like the left wrist is swollen from inside.

Current Medications: metformin 500mg B.D. PO

Allergies: there are no known food or drug allergies.

Past Medical and Surgical Hx: she was diagnosed with type 2 diabetes mellitus three years ago, and she is on treatment. There is no history of surgeries or caesarian sections in the past.  She is not hypertensive. The last flu shot was last year. She can’t remember the last tetanus toxoid vaccine.

Soc Hx: she has been working as a hairdresser for the past twenty years. She enjoys watching movies during her free time. She occasionally takes a maximum of two bottles of beer during the weekend with friends. She does smoke tobacco or uses recreational drugs. She does not use her cellphone while driving. She uses her seatbelt all the time.

Family Hx: the husband is hypertensive and has been on care for two years now. No history of diabetes in the family. Her two children (a son, 21, and a daughter, 17) are healthy. No known genetic illnesses in the nuclear and extended family part from her maternal uncle, who is diabetic hypertensive.

ROS:

GENERAL:  no night sweats, no weight loss, fever, chills, weakness, or fatigue.

HEENT: Head: no headache, no history of head trauma; Eyes: no double vision, no vision loss, no watery eyes; Ears: no discharge, no hearing loss, no ringing sounds in the ears; Nose: no congestion, no drainage, no bleeding; Throat: no sore throat, no pain, no difficulty swallowing

SKIN:  no skin rashes, no changes in skin pigmentation, no itching.

CARDIOVASCULAR:  no leg swelling, no orthopnea, no chest pain, no palpitations

RESPIRATORY:  no chest pain, no cough, no difficulty in breathing

GASTROINTESTINAL:  No abdominal pain, no vomiting, no early satiety, no difficulty passing stool, no heartburn.

GENITOURINARY:  no dysuria, no hematuria, no vaginal discharge, or itching. The last menstrual period started 14 days ago and lasted four days. There is no significant pain during menses. The menses have been irregular in the past five years, occurring between 20 days and 33 days apart.

NEUROLOGICAL:  no change in bowel and bladder patterns, no dizziness, no headache, or syncope,

MUSCULOSKELETAL: right wrist pain, no joint stiffness, or muscle pain.

HEMATOLOGIC:  no easy fatiguability, no epistaxis, no syncope, no bleeding

LYMPHATICS:  No enlarged nodes in the neck or armpit. No history of splenectomy.

PSYCHIATRIC:  No history of psychiatric admissions, no history of depression.

ENDOCRINOLOGIC: no cold or heat intolerance. No polyuria or polydipsia. No goiter

ALLERGIES:  No history of asthma, hives, eczema, or rhinitis.

Objective Data.

General: she is obese but well-appearing. BP = 132/87 mmHg, RR = 20, HR = 97, Oxygen saturation 95%, BMI = 32. Regular rate and rhythm of pulses on the cardiac exam. The right radial pulse is faint but regular.

HEENT: Head: no bruises or scars; Eyes: pupils are equal round, and reactive to light, accommodation is good, extraocular muscles intact: Ears: no discharge, tympanic membrane not erythematous; Nose: no bleeding, no drainage; Throat: no tonsillar swelling, or exudate, no Thrush.

NEUROLOGICAL EXAM:

Mental Status: the patient is oriented to time, place, and person. She maintains eye contact and interacts actively with the clinician.  Her speech is coherent and fluent. Her remote and recent memory is intact. She recalls 4/4 objects at 5 minutes.

Cranial Nerves: cranial nerves I-XII intact,

Motor Systems: muscle power 5/5 for knee ankle, hip, and shoulder muscle groups. The power of the thenar muscles is 4/5, with no reduction of bulk and tone.  All reflexes are 2+ in the ankle, knee, elbow, and wrist muscle groups bilaterally. The carpal compression test is positive.

Sensory System: a sense of touch and pinprick reduced over the skin on the right thenar eminence and lateral half of the right palm in comparison to the left hand. Flexion of the right wrist is reduced, so are flexion of the thumb, index, and middle fingers on the right hand. The extension of the right wrist is full.

Coordination and Balance: absent Romberg test, no gait disturbances, finger nose test coordination intact.

Diagnostic Plan

  1. Random blood sugar: the assessment of random blood sugar would be useful in detecting the current effectiveness of glucose control in the past few hours
  2. HbA1c: to assess the quality of the glucose control in the past 2-3 months
  3. MRI of the right wrist: the patient reported a feeling of “swelling and heaviness in the right wrist.” MRI would be useful in ruling out space-occupying lesion in the right wrist
  4. Electrophysiologic examination of the right wrist: these studies would provide more accurate results of the extent of damage of the nerves in the carpal tunnel.

So far, no lab results are available.

Assessment

  1. Carpal tunnel syndrome: paresthesia over the palmar surfaces of right thumb, index, and middle fingers, right wrist pain (Ashworth & Klein, 2020), reduced flexion of the thumb, index, and middle fingers, decreased sensory function of the lateral half of the right palm. Her risks for developing arthritis is diabetes mellitus, female gender, and obesity.
  2. Diabetic neuropathy: the patient is a known diabetic for three years; diabetes is a known risk factor for Carpal Tunnel Syndrome. However, the mechanism remains unclear (Genova et al., 2020).
  3. Overuse injury of the right wrist: the patient is a hairdresser for 20 years; she regularly uses her hands to perform her work. Besides, she is right-handed.
  4. Osteoarthritis of the right wrist: wrist pain; pain is a sign of inflammation, among other etiologies.
  5. Obesity: the patient’s BMI is 32; the lower cutoff for obesity is 30.

Plan.

Tylenol 650mg TDS, P.O. to manage the pain.

Referral: the patient would be referred to an orthopedic surgeon to manage carpal tunnel syndrome. She would also be referred to a dietician for her obesity. She would also need to visit an occupational therapist to advise her on her hairdressing job and associated risk factors.

Patient education: the patient would be educated on lifestyle modification such as regular exercises, weight control, cutting down alcohol intake. She would also be advised on the need for medication adherence. She would take the Tylenol as strictly as prescribed. She should also be announced on the correct positioning of the wrist joint and avoid exacerbators of the wrist pain

Health follow-up and maintenance: she would continue taking her metformin as prescribed with her blood sugars’ regular charting daily. She would be provided with a glucometer. Her blood pressure also needs daily monitoring (Whelton et al., 2018).

References for Episodic/Focused SOAP Note Right Wrist Pain and Numbness 

Whelton, P., Carey, R., Aronow, W., Casey, D., Collins, K., & Dennison Himmelfarb, C. et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal Of The American College Of Cardiology, 71(19), e127-e248. https://doi.org/10.1016/j.jacc.2017.11.006

Ashworth, N., & Klein, M. (2020). Carpal Tunnel Syndrome: Practice Essentials, Pathophysiology, Epidemiology. Emedicine.medscape.com. Retrieved 29 October 2020, from https://emedicine.medscape.com/article/327330-overview?src=mbl_msp_android&ref=share.

Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal Tunnel Syndrome: A Review of Literature. Cureus, 12(3), e7333. https://doi.org/10.7759/cureus.7333