Propose a soap note on the above patient including required

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Reference no: EM133839370

Problem

Nora, a 45-year-old woman (she, her, hers), is being seen in the office for her yearly wellness exam. She has episodes of waking up at night because of pain in her right hand with numbness and tingling in her fingers. Nora is concerned because it seems she also has trouble opening jars. On occasion, Nora has neck pain that is relieved with acetaminophen. She is right-handed.

History

1) PMH: Hypertension, diabetes mellitus type 2 (diagnosed 2 years ago). A1C 1 last visit was 6.5%.
2) Allergies: NKA
3) Medication: Lisinopril 20 mg daily, metformin 750 mg bid

Social History

1) Occupation: Stocker at a grocery store. Currently enrolled in online administrative courses.
2) Does not smoke. Denies use of marijuana or illicit drug use.
3) Drinks 2 or 3 glasses of wine per week.

Physical Exam

1) Height: 67 inches
2) Weight: 195 pounds
3) BP: 150/92; HR: 72 reg; R: 16
4) Range of motion (ROM) of neck: mildly limited with rotation to right
5) Muscle strength: 5/5 and symmetric in all muscle groups; full range of motion in all extremities
6) Deep tendon reflexes: 2/4 (normal)
7) No atrophy of thenar muscle
8) Positive Tinel's sign at right wrist
9) No decrease in sensation in fingers or bottom of feet. Get the instant assignment help.

Propose a SOAP note on the above patient including required labs to be collected, diagnostic tests to be performed, three differential diagnosis with reasons and a primary diagnosis.

Reference no: EM133839370

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