NURS 6512 Week 9 Case Study 2 Assignment: Assessing Neurological Symptoms SOAP NOTE

Case Study Assignment: Assessing Neurological Symptoms
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.

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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.

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Week 9: Shadow Health Comprehensive SOAP Note Template

Initials: D.T Age: 47yo Sex: Female Race: Caucasian

SUBJECTIVE DATA:

CC: “I have right wrist joint pain and numbness and tingling sensation on the right-hand fingers.”

HPI: The client, D. T, is a 47yo Caucasian female. The client presented to the clinic complaining of pain in her right wrist joint. She adds that the pain is accompanied by tingling sensations and numbness in three fingers, including the thumb, middle, and index fingers. The client reports that the pain had persisted for two weeks. The pain has been increasing gradually since its onset. The pain is 2/10 when the wrist is immobile. The pain increases to 6/10 when moving the joint. She described the pain as aching radiating to the forearm’s ventral side. The pain is increased by moving the joint repeatedly. She takes over-the-counter ibuprofen to relieve the pain. She reports being frustrated by the pain since it’s making her drop hair styling tools.

Current Medication:

Oral ibuprofen 400 mg orally taken to relieve the pain.

Allergies: No known allergies.

PMH: Has hypertension and manages it using hypertensive treatment.

Soc Hx: The client works as a hairstylist at a local beauty spa. She reports taking alcohol and smoking cigarette occasionally. She denies using illicit drugs.

Fam Hx: The client has two siblings who are alive. Their lastborn was diagnosed with schizophrenia. Her father has cancer of the esophagus and is hypertensive. Mother has diabetes and hypertension.

ROS

GENERAL: The client denies fatigue or weakness.

HEENT: She denies head trauma. Denies eye discharge. Denies tinnitus. Denies nasal blockage. Denies difficulty in swallowing.

SKIN: Denies skin rashes.

CARDIOVASCULAR: Denies orthopnea.

RESPIRATORY: Denies rapid breathing.

GASTROINTESTINAL: Denies diarrhea or vomiting.

GENITOURINARY: Denies burning sensation.

NEUROLOGICAL: Denies dizziness. Reports are tingling sensation and numbness in three fingers, including the thumb, middle, and index fingers.

MUSCULOSKELETAL: Reports right wrist pain. She rates the pain as 2/10 when immobile and 6/10 with movement.

HEMATOLOGIC: Denies bleeding.

PSYCHIATRY: Denies suicidal ideation

ENDOCRINOLOGIC: Denies polydipsia.

ALLERGIES: Denies eczema.

OBJECTIVE DATA

Vital signs: BP- 137/89 mmHg, RR-18, PR-88, SpO2-97%, Temp- 97, Wt- 153 lbs., Ht- 5’11”, and BMI score 21.3

General: The client is well-developed, nourished, and presentable. She maintains an upright posture and eye contact throughout the interview.

HEENT: Head: No scars seen on the head. No eye discharge. No discharge from the ears. Pink and moist nasal mucous membranes. No tonsils were detected.

Neck: No swellings or scars on the neck.

Musculoskeletal: On touch, the right wrist seems to be in pain. Her right thumb abduction is weak. Her strength is 3/5.

Skin: No rashes with a normal skin turgor.

Cardiovascular: No chest deformities.

Respiratory: Symmetrically equal chest expansion.

Gastrointestinal: Bowel sounds were audible in four quadrants.

Genitourinary: No vaginal discharge.

Neurological: Good mood noted.

Diagnostic tests:

HbA1c

Gupta et al. (2017) recommend HbA1c to evaluate blood sugar levels. Thus, a healthcare provider would use the results of the HbA1c test to rule out diabetes in this patient.

ASSESSMENT

Differential diagnosis

Potential diagnoses for this client are listed below, starting with the most likely to the less likely diagnosis.

Carpal tunnel syndrome – Primary diagnosis.
Thoracic outlet syndrome

Diabetic peripheral neuropathy

Acute Compartment Syndrome
Cervical Myofascial Pain

Carpal tunnel syndrome: This condition qualifies as the client’s primary diagnosis since it is characterized by reported symptoms, including pain in the median nerve and numbness Genova et al. (2020).

Thoracic outlet syndrome: This condition is characterized by pain in the neck and shoulders. Patients also experience finger numbness on the affected side (Illig et al., 2021). The client might have this condition since she reported a tingling sensation and numbness in the fingers. However, it is ruled out since pain is not occurring in the shoulders or neck.

Diabetic peripheral neuropathy: According to Iqbal et al. (2018), the risk of this disease is high among individuals with diabetes mellitus and those hypertensive. The client might have this condition since she has a family history of diabetes and is on hypertensive treatment.

Acute Compartment Syndrome: This condition is characterized by intense pain that worsens when muscles stretch, tingling, and numbness. The client might have this condition since she reports wrist pain that worsens with movement, tingling sensation, and numbness in the fingers.

Cervical Myofascial Pain: This condition is characterized by aching, tight, stiff, or throbbing pain and muscle weakness. She might have this condition since she reported pain in her wrist. However, this condition is ruled out due to the absence of muscle weakness.

References

Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal tunnel syndrome: a review of the literature. Cureus, 12(3).

Gupta, S., Jain, U., & Chauhan, N. (2017). Laboratory diagnosis of HbA1c: a review. J Nanomed Res, 5(4), 00120.

Illig, K. A., Rodriguez-Zoppi, E., Bland, T., Muftah, M., & Jospitre, E. (2021). The incidence of thoracic outlet syndrome. Annals of Vascular Surgery, 70, 263-272.

Iqbal, Z., Azmi, S., Yadav, R., Ferdousi, M., Kumar, M., Cuthbertson, D. J., … & Alam, U. (2018). Diabetic peripheral neuropathy: epidemiology, diagnosis, and pharmacotherapy. Clinical therapeutics, 40(6), 828-849.