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S.Chief Complaint: “I am having numbness, tingling and discomfort in my left wrist resulting indifficulties holding onto curling iron at work”.HPI: 48-year-old female presents with tingling, numbness and pain in L hand that started about3 weeks ago and is worsening gradually. affected areas are middle fingers andthe thumb indexof her left hand.Location: middle finger and the thumb index, right handOnset: 3 weeks agoCharacter:Associated signs and symptoms: discomfort, tingling and numbnessTiming:Exacerbating/ relieving factors:Severity: 6/10 pain scaleCurrent Medications: Prevacid25 mg daily, Ibuprofen 800 mg BID-TID for pain estradiol patcho.2 mg once every week, , Progesterone 300 mg daily.Allergies:nonePMHx: Up to date on immunizations Last Tdap 2015 / Flu Fall 2016.Denies other significant medical/surgical hx.Denies any trauma to the hands.Soc Hx: 47 years old female who works 10 hours a day as a hair dresser at Great Clips inBatavia Ohio during the week from 9am- 3pm Monday through Friday. On the weekends, baby
sits her 3 grandchildren and occasionally will do hair on private clients at home for extra money.Has 2 sons and 3 daughters. Currently lives in a 3 bedroom condo with her husband and2
Daughters. Sexually active with one partner. Goes to a Christian church in the neighborhood withthe family on Sundays. Denies exposure to domestic violence. Denies ETOH, tobacco use orillicit drug use. Denies recent travel.Fam Hx: Mother alive, age 66, hx of diabetes ,depression, obesity (onset age 57)Father alive, age 68, no significant hxGrandparentsMaternal grandmother, age 80, arthritis (age 60) / diabetes (age 52)Maternal grandfather, age 82, hypertension (age 70).Paternal grandmother, 83 – no significant historyPaternal grandfather, died of prostrate cancer with mets to the kidney at the age of75 years.ROS:GENERAL: Denies change in weight, fatigue, weakness, chills or fever. Denies any recentsickness.HEENT: Eyes: Wears reading glasses. Denies diplopia or loss/blurred vision. Denies trauma orhx neck pain. Ears: hearing unaffected. Denies recent URI, sore throat orNasal congestion,SKIN: No rash, pain or itching. Has observed certain discolorations on her faceCARDIOVASCULAR: Denies any pressure, palpitations or chest discomfort.

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