MN566 SOAP MOSES SINCLAIR

Name: Moses Sinclair

 Pt. Encounter Number: 456789

Date: 06/1/2024

Age: 68

Sex: Male

SUBJECTIVE

CC:  

“I am having pain in my right hand for 3 months.”

HPI:  

Patient complains of right hand and wrist pain and weakness for 3 months ago. “It lasts all day but not constant pain.”  “It’s an achy pain and an elecrtrical shock feeling.” Patient states the more he uses his right hand, the more it aches. Rubbing his right hand helps with the pain a little and takes a Tylenol ES during the day helps a little as well.   The pain is “pretty bad” in the afternoon, patient states, 7 out 10 on severity.  

Medications: 

Patient taking OTC Tylenol ES at this time, denies any prescribed medications, herbs or supplements; past or present

Allergies: NKDA

Medication Intolerances: None

Past Medical History: None

Chronic Illnesses/Major traumas: None, Denies any major traumas.

Hospitalizations/Surgeries: None

Family History: Diabetes and Stroke runs in family; Father-age 91, alive, Type II Diabetes and on insulin; Mother-age 90, alive, had stroke 10 years ago when she was 80, doing well. Sister-passed away at age 67 due to heart disease.

Social History:

Patient is a carpenter.  Patient lives with his wife in a single-family home. Patient denies smoking, alcohol and drug use.  Patient is sexually active.   Patient is up-to-date with immunizations.  Patient hasn’t had any cancer screenings.

Review of Systems

General 

Denies weight change, fever, chills, night sweats.  Patient c/o fatigue, feeling more tired as of late

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, and edema

Skin

 Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Denies corrective lenses, blurring, and visual changes of any kind

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine; sexually active, denies STDs

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis.

Complains of right hand and wrist pain and weakness, achy, “electrical shock” sensation

Breast

Denies lumps, bumps, or changes

Neurological

Denies syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

Heme/Lymph/Endo

Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Psychiatric

Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx 

OBJECTIVE

Weight: 195 lbs (88.6kg) 

BMI: 28.8

Temp: 98.6F (36.7C)

BP:134/64 

Height: 5’9” (175 cm)

Pulse: 75

Resp: 20

General Appearance

Patient appears healthy and well-nourished in mild distress and pain.  Patient’s personal hygiene is intact, patient’s hair and teeth appear clean.  Patient is not malodorous.  Dress is appropriate for the weather.  Clothes appear clean and in good condition, no odor, stains or holes visible. 

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. 

Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection, anicteric, fundus WNL, no 

papilledema. Diabetic retinopathy.

Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized.

Nose: Nasal mucosa pink; normal turbinates. No septal deviation. 

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.  Trachea midline, mobile. No masses, JVD or carotid bruit.  

Mouth/Throat: Oral mucosa, pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, symmetric, nontender., (-) guarding.  No masses, no visible lesions or scars.  Liver exam – nontender to palpation.  Liver span – 10 cm, WNL.  

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

No edema, erythema, or tenderness.

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.  Limited ROM to right hand and wrist, pain with movement, no swelling or bruising noted to right hand and wrist, bilateral radial pulses palpated, 2+, WNL, Tinel’s and Phalen’s: Positive; Pinch Test to right hand , decreased strength.

Neurological 

Speech clear. Good tone. Posture erect. Balance stable; gait normal. Cranial Nerves II-XII intact. DTR: Biceps, Corachobrachialis, Patella, Achilles 2+, WNL.  

Psychiatric

Alert and oriented. Dressed in pants and shirt. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

None

ASSESSMENT

Differential Diagnoses

PLAN

Non-Pharmacological Recommendations

Patient Education

Culture Considerations

Health Promotion

Referrals

Follow-Up