67%(3)2 out of 3 people found this document helpful
This preview shows page 1 - 3 out of 5 pages.
CASE STUDY: Numbness and Pain Patient Information: CK, 47, Female, Caucasian S.CC:numbness and pain in the right wrist HPI:47-year-old Caucasian obese female presents to the clinic with reports of right wrist pain, 6/10 with tingling and numbness in the thumb, index, and middle finger for 2weeks. The patient reports she is a hairdresser for the last 20 years and expressed frustration because the pain causesher to drop her work tools. Pt denies associated signs and symptoms. The patient stated she was at work when the pain, tingling, and numbness occurred, and the pain often wakes her up at night. The patient reports that she usually “shake out” her hand and wear a splint she got over thecounter to relieve symptoms. Reports doing several activities with her hand at work causes more pain. Current Medications: DM type 2, metformin 500mg BID for two years but self-discontinued one year ago, “I didn’t feel I had diabetes.” Multivitamin daily for 20 years. Allergies:denies medication, food, and environmental allergies PMHx: immunization up to date, last tetanus five years ago when she stepped on a nail at work. Diagnosis in 2010 with diabetes type 2. hospitalized last year for pneumonia for three days. No major surgeries past major illnesses and surgeries. Soc Hx:works at a salon as a hairdresser for 20 years, enjoys reading and watching television. Married with one adult child. Denies tobacco use and reports to drinking wine with dinner or
weekends to relax. Denies any other drug use. Patient reports wearing a safety belt while driving,denies exercise and described diet as “steak and potatoes.”, Fam Hx: Mother died three years ago from DM Father died in car accidents at age 59 ten years ago Grandparents both deceased before the patient was born.