Assignment: Focused SOAP Note of a 47 Year-Old Obese African American Female with Carpal Tunnel Syndrome Case Study

Assignment: Focused SOAP Note of a 47 Year-Old Obese African American Female with Carpal Tunnel Syndrome Case Study

Assignment: Focused SOAP Note of a 47 Year-Old Obese African American Female with Carpal Tunnel Syndrome Case Study

CASE STUDY

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.

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To Prepare
• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, 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.

The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

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A Sample Of This Assignment Written By One Of Our Top-rated Writers

Focused SOAP Note of a 47 Year-Old Obese African American Female with Carpal Tunnel Syndrome  

Patient Information: Initials: R.B.      Age: 47     Sex: F      Race: African American

S.

CC (chief complaint): The 47 year-old African American woman who is a hair stylist presented complaining of pain and numbness coupled with a “tingling sensation” on the thumb, the middle finger, the index finger, and the wrist on her right hand for the past two weeks.

HPI: The patient is a 47 year-old African American female presenting with the above complaints. The location of her symptoms is the right hand and the symptoms started two weeks ago. There is numbness, tingling, and pain in the wrist and the mentioned fingers. An associated symptom is limpness of the affected right hand. The timing of the symptoms is after her hair styling work at the end of the day. Taking acetaminophen somewhat relieves the pain but not the numbness and tingling sensation. Exacerbation occurs when she does the hair of a customer. She rates the severity of her symptoms at 8/10.

Current Medications: Currently not on any prescribed medication save for OTC Tylenol 500 mg prn.

Allergies: NKA

PMHx: Never been admitted or ha surgery before. She had all her immunizations as a child. She has also received booster doses of pneumonia and tetanus (2012 and 2018) as well as two doses of the Moderna Covid-19 vaccine (12/8/2021 and 03/03/2022).
Soc Hx: She never smokes but drinks socially with friends over the weekends. Her hobbies are watching movies and eating out. She has a boyfriend but has no children and has never been married. She lives in a safe neighborhood with enough lighting and security. There are smoke detectors in the house and she always uses the seatbelt when driving.

Fam Hx: There is a history of obesity, type II diabetes, and hypertension in the family on the side of the mother. Mother died of myocardial infarction.

ROS:

GENERAL:  Denies fever, chills, weight loss, or fatigue.

HEENT:  Negative for photophobia, blurring, tinnitus, otorrhea, rhinorrhea, sneezing, or sore throat.

SKIN:  Negative for eczema, itching, or rashes.

CARDIOVASCULAR:  Negative for chest pains, edema, or palpitations.

RESPIRATORY:  Negative for dyspnea or wheezing/ coughing.

GASTROINTESTINAL:  Denies altered bowel movements, nausea, diarrhea, or vomiting.

GENITOURINARY:  Denies dysuria or frequency of micturition. LMP: 11/03/2021.

NEUROLOGICAL:  Denies headache, fainting, paresis, ataxia, or loss of bladder and bowel control.

MUSCULOSKELETAL:  Denies joint or muscle pains. She is POSITIVE for right wrist pains and inability to hold objects well with that right hand.

HEMATOLOGIC:  Negative for blood and clotting disorders including anemia.

LYMPHATICS:  Negative for lymphadenopathy or splenectomy.

PSYCHIATRIC:  Negative for depression or anxiety.

ENDOCRINOLOGIC:  Negative for excessive thirst, taking of a lot of water, cold intolerance, heat intolerance, or past hormonal therapy.

ALLERGIES:  Negative for eczema, rashes, or any other allergies.

O.

Vital Signs: T 98.3; BP 135/85; HR 72; RR 16; BMI 31 kg/m²

Diagnostic results:

• Full blood count 7,500 (no leucocytosis) hence no infection (Hammer & McPhee, 2018).
• Full metabolic profile shows elevated low-density lipoprotein (LDL) cholesterol (186 mg/dL)
• Right hand X-ray shows no fractures or sprains (Genova et al. 2020; Kamath et al., 2016; Sandbrink, 2019).
• Elevated HbA1c of 6.4% showing a pre-diabetes status (Hammer & McPhee, 2018; Lind et al., 2019).

A.

Differential Diagnoses

1. Carpal tunnel syndrome (CTS): This is the primary diagnosis that is the most likely for this patient. All the classic and characteristic presentations of CTS are present. They include numbness, a tingling sensation on the wrist, and pain in the affected area. CTS is also linked to professions in which the patient regularly uses motions that twist the wrist. This patient is a hair stylist and therefore fits the bill (Genova et al., 2020; Sandbrink, 2019).
2. Diabetic neuropathy: This patient has an elevated HbA1c test of 6.4% that indicates that she is already experiencing symptoms and signs of type II diabetes. She is in the prediabetic state and will soon show full-blown type II DM. diabetic neuropathy is a known microvascular complication of diabetes (Hammer & McPhee, 2018).
3. Wrist arthritis: Obesity as a condition also predisposes to conditions such as arthritis in a woman like this patient who is above 45 years old (Hammer & McPhee, 2018). This is also a possible differential diagnosis for this patient even though the radiologic investigation of an X-ray did not reveal any obvious abnormalities in the musculoskeletal architecture of the affected wrist.

References

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

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Kamath, J.B., Jayasheelan, N., & Danda, R. (2016). Combined median and ulnar nerve compression neuropathy due to lipoma at the wrist. Journal of Hand and Microsurgery, 8(1), 59–60. http://dx.doi.org/10.1055/s-0036-1581122

Lind, M., Pivodic, A., Svensson,  A., Ólafsdóttir, A.F., Wedel,  H. & Ludvigsson, J. (2019). HbA1c level as a risk factor for retinopathy and nephropathy in children and adults with type 1 diabetes: Swedish population based cohort study. BMJ, 366, l4894. http://dx.doi.org/10.1136/bmj.l4894

Sandbrink, F. (March 18, 2019). Median neuropathy clinical presentation. Medscape. https://emedicine.medscape.com/article/1141168-clinical#b1