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1Week 9 Case StudyAriana Whetsell, RNNURS 6512: Advanced Health AssessmentWalden UniversityDr. Mary SizemoreAugust 1, 2021
2Week 9 Case StudyFor this assignment, students were asked to review a patient case study related to theneurological system.Students were then to format a SOAP note for patient.5 Differentialdiagnoses with evidence-based research are to be provided.Lastly, diagnostic testing specific forthis patient will be noted.SOAP NotePatient Information:Name: TGAge:47-year-oldSex:FemaleCCRight wrist numbness and painHPI: Patient is a 47-year-old Caucasian female presenting with right wrist painLocation: Right wristOnset: 2 weeks agoCharacter: Tingling/ numbnessAssociated signs and symptoms: Difficulty grasping toolsTiming: IntermittentExacerbating/ relieving factors: Exacerbated by movements of wrist, when styling hair; Relief byrestSeverity: 7/10 during most painful occurrencesCurrent Medications: Synthroid 75mcg PO daily; Zoloft 40 mg PO dailyAllergies:Denies medication, food or latex allergies. Denies environmental allergiesPMHx: Hypothyroid; C-section x3; migraine headaches; depression; obesity. Denies othersurgical hx.Flu vaccination (10/2020); Moderna Lot #ID5627 on 7/25/2021 and 6/20/2021Soc Hx:Patient is hairdresser for last 15 years, working 4 days a week.She lives at home withhusband; Has three children- ages 20,25 and 29- who live away from home.She denies safety orabuse concerns. Denies tobacco use. Reports drinking one glass of red wine with dinner threetimes a week; Denies recreational drug use. Reports good support system with family and churchcommunity.