Episodic/ Focused SOAP Note on a patient with Carpal Tunnel Syndrome (Assignment 1: Case Study Assignment: Assessing Neurological Symptoms). Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks.
CASE STUDY 2:
Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools. To Prepare Your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. With regard to the case study you were assigned: Review this week’s Learning Resources, and consider the insights they provide about the case study. Consider what history would be necessary to collect from the patient in the case study you were assigned. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Episodic/ Focused SOAP Note on a patient with Carpal Tunnel Syndrome– wrist exam soap note
Patient Particular Initials: (J.D) – for Jane Doe Age: 47 years Gender: female race/ethnicity: African American
Subjective (subjective objective assessment plan):
CC (chief complaint): ‘I have pain in my right wrist
HPI: J.D. is a 47-year-old female of African American race who presents to the clinic complaining of right-wrist pain, with tingling and numbness in the thumb, index, and middle fingers whose onset was two weeks ago. She reports that she shifted her keyboard at the workplace and anticipates that this gesture will help alleviate the pain. Her concern with the carpal tunnel hinges on how she performs many repetitive tasks. She reports noting that the pain worsens t night, mainly if she sleeps at a certain angle. The pain mainly involves the middle finger, which could indicate arthritis.
Pain History in Mnemonic LOCATES format
Location Right wrist
Onset: two weeks ago
Character: burning sensation
Additional symptoms: tingling sensation, numbness
Timing- At night, while sleeping
Exacerbating factors Repetitive hand maneuvers, sleeping in a certain angle Relieving factors changing the position of the hand, Tylenol 500mg Q 6hr PRN
Severity: 5/10
Obesity seems to increase the intensity of her pain further.
Current Medications: the patient takes semaglutide 2.4 mg (wegovy) subcutaneously, once a week, and on the same day every week.
OTC- Tylenol 500mh Q6hr PRN
Allergies: There are no known allergies either by food, medication, or environmental factors.
Past Medical History: J.D. reports receiving all the vaccinations but has no proof. She admits to being obese in the past.
Past Surgical History: Denies known surgeries in the past.
Reproductive History: Negative for STIs and gynecological issues
Social History: the patient denies substance abuse.
Health Maintenance:
Reports going for cervical cancer screening tests and having her breast cancer screening the last time being 6 months ago. She attends gym only if her 22 yo daughter, currently in college, is around.
No other health promotion activities
Immunization History: Positive for all vaccinations.
Family History: The client reports having a family pedigree of arthritis as both parents, and paternal grandparents succumbed to different types of arthritis.
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ROS:
General: she denies feeling hot. She reports unusual weight gain, wrist pain, and numbness in the thumb, index, and middle fingers.
HEENT: No head injuries or scars. Alert to sight and negative for bloodshot eyes. Reports no sound impairment. Negative for nose bleeding, running nose, and nose tumor. She has no sore throat.
Respiratory: negative for phlegmand shortness of breath.
Cardiovascular: No palpitation and negative for chest pains or discomfort.
Gastrointestinal: No vomiting, diarrhea, and lactose intolerance.
Genitourinary: she denies burning sensation during urination.
Musculoskeletal: she reports no muscle stiffness or pain.
Neurological: no headache or instability in walking.
Psychiatric: she denies having any psychiatric issues. (wrist carpal tunnel syndrome)
Skin/hair/nails:
Skin positive for alopecia
No itchy sensation
Nails negative for dystrophy
No hair issues
Objective:
Physical Exam: The lady is well-groomed for the clinic’s visitation and walks at a slow pace.
Vital Signs:Heart Rate: 86; respiratory rate: 20; Temperature: 98.9F; Blood pressure: 119/80; Height: 55 inches; Weight: 182 lbs.; MBI: 31. The patient’s weight is too high, the reason for obesity.
HEENT: Norm cephalic head with no abnormal curves. Eyes normal with round and equal pupils, no bloodshot or eye redness. Pearly white eye drum and positive for ear wax symbolizing no ear infection. By palpitation, nose smooth with no tumors. No coughs or phlegm in the throat.
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Neck: By palpitation, standard lateral deviation, no neck tumor, and negative for neck lymph node inflammation.
Chest: negative for chest pains.
Peripheral vascular: Noissues with thepulses and perfusion.
Abdomen: Normal abdomen shape and through auscultation, no bowel obstruction.
Genital: Negative for hernia andnormal external genital of a female.
Musculoskeletal: No joint stiffness or pain.
Neurological: no unusual bowel movement.
Skin: Normal turgor with no lesions.
Diagnostic results:
i. Magnetic resonance imaging (MRI) was ordered to provide a clearer picture of any abnormal tissue in the wrist. The result was negative for vein and arteries problems.
ii. X-rays it is the common test for wrist pain to identify whether the client has a bone fracture. The results are negative for bone fractures.
iii. Nerve test using an electromyogram to help determine if the patient has carpal tunnel syndrome since it is the suspected problem in our patient. The results are positive for Carpal tunnel syndrome. (SOAP Note on a patient with Carpal Tunnel Syndrome)
Differential Diagnosis:
- G 56.00 Carpal Tunnel Syndrome confirmed
Carpal tunnel syndrome is a general condition characterized by hand and wrist pain, numbness, tingling, and weakness. It occurs when raised pressure on a median nerve is found in the wrist. The median nerve offers sensation to the middle fingers, the index, and the thumb. The patient complains of wrist pain and thumb, index, and middle finger numbness. These signs were present in the patient belonging to carpal tunnel syndrome and, therefore, instrument in confirming a CTS diagnosis (Wipperman & Goerl, 2016).
- Cubital Tunnel Syndrome (Refuted)
The symptoms of carpal tunnel syndrome and cubital tunnel syndrome have similarities, but their specific location differs. The latter pain manifests in the tiny and ring fingers or when laughing, and therefore I refused. Its counterpart, carpal tunnel syndrome, affects the thumb, index, and long finger. Andrews et al. (2018) opine that this is the second most prevalent pain of neuropathic origin. Electromyography can also help in confirming cubital tunnel syndrome.
- Cervical Radiculopathy refuted
is a clinical description of the damage of the cervical spine leading to alteration of neurological function. It involves numbness, reflexes, alternation, or weakness, from the neck to the shoulder, hand, fingers, or arm. One may also experience tingling or pain. According to Ghaly & Ghaly (2019), the condition is refuted since the patient does not have pain in the neck or shoulders.
- Arthritis refuted
The swelling of joints may affect either one or multiple joints. There are many types of arthritis, and their symptoms include joint pain, inflammation, and stiffness. Both conditions can trigger tingling or numbness in hand and weakness in grasping objects. These symptoms tend to feel worse when one stands up after resting or gets out of bed. The client could not be arthritis positive because her pain is constant, whether after a rest or not. However, it was ruled because arthritis is caused by joint damage or inflammation, which were not found in the scans but Nerve compression was established.
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- De Quervain’s tendinosis refuted
This is a condition in which inflammation affects either the wrist or the base of the thumb. Here, pain occurs whenever one makes a fist and simulates while shaking hands. Performing a wrist ultrasound at different angles provides a clear picture of the tendons affected together with the surrounding tissue. However, the scan did not confirm injured tendons; thus, it helped clarify the diagnosis. J.D. could not suffer from this condition as the pain persists even without simulation during shaking hands.
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References
Andrews, K., Rowland, A., Pranjal, A., & Ebraheim, N. (2018). Cubital tunnel syndrome: anatomy, clinical presentation, and management. Journal of orthopedics, 15(3), 832-836.
Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal tunnel syndrome: a review of the literature. Cureus, 12(3).
Ghaly, B., & Ghaly, S. (2019). The Use of Neuromuscular Ultrasound and NCS/EMG Testing in the Differential Diagnosis of Carpal Tunnel Syndrome and Radiculopathy. The Neurodiagnostic Journal, 59(1), 23-33.
Mak, J. (2018). De Quervain’s Tenosynovitis: Effective Diagnosis and Evidence-Based Treatment. In Work-related Musculoskeletal Disorders. IntechOpen.
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Spel, L., & Martinon, F. (2020). Inflammasomes contribute to inflammation in arthritis. Immunological Reviews, 294(1), 48-62.
Wipperman, J., & Goerl, K. (2016). Carpal tunnel syndrome: diagnosis and management. American family physician, 94(12), 993-999.
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