SOAP / Chart / Progress Notes
Sample Name: SOAP - Numbness & Tingling
Description: Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.
(Medical Transcription Sample Report)
SUBJECTIVE: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.
OBJECTIVE: Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. General: The patient is nontoxic and in no acute distress. Musculoskeletal: The right hand was examined. It appears to be within normal limits and the appearance is similar to the left hand. She has good and equal grip strength noted bilaterally. She has negative Tinel's bilaterally. She has a positive Phalen's test. The fingers on the right hand are neurovascularly intact with a normal capillary refill.
ASSESSMENT: Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. I suspect carpal tunnel syndrome.
PLAN: The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time. She is going to let me know. While she is here, I am going to also get her the blood test she needs for her diabetes. I am noting that her blood pressure is elevated, but improved from the last visit. I also noticed that she has lost a lot of weight. She is working on diet and exercise and she is doing a great job. Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.
Keywords: soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling,