Episodic/Focused SOAP Note TemplatePatient Information: T.L., 47, Female, CaucasianS.CC: Pt has compliant of pain in her right wrist and tingling and numbness in her thumb, index, and middle finger of the right hand. HPI: T.L. is a 47 year old women that states that she has been having pain for the last two weeks in her right wrist. while experiencing tingling and numbness in her thumb, middle, and index finger on that hand. She states that the she has been dropping her hairstyling tools and it is causing her frustration. She rates the pain as a 5/10.Current Medications: 1.Ibuprofen 200mg PO PRNAllergies: 1.Pt denies any medication, food, latex, or environmental allergies.PMHx: Pt is up to date on all her immunizations. Pt’s last tetanus shot was 3 years ago after stepping on a rusty nail in her garage. Pt has no medical conditions, and has never been hospitalized. Pt received her flu shot last year and got her COVID vaccinations, Moderna in May and June of 2021. Soc Hx: T.L. works as a hairstylist at Europa Salon and Spa in Coralville Iowa. She works 10 hour days Wednesday through Saturday. She is divorced and has no children. Pt denies smoking or drinking alcohol. Pt states she has never tried any illegal substances such as marijuana or narcotics. Pt states she always wears her seat belts and has no concern for her safety. Pt denies any depression or anxiety.Fam Hx: Mother: 69, Hypertension, Diabetes Mellitus Type 2Father: Deceased at age 70, 2 years ago from lung cancer. Former smoker, COPD. Maternal Grandmother: 92, hypertension© 2021 Walden University, LLC Page 1 of 5
