Scenario: 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

Scenario: 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Comprehensive SOAP Note Template

Patient Initials: _BG_                       Age: _47_                            Gender: _F                    Race: African American

 

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): 

 

History of Present Illness (HPI): 

Location:

Onset:

Character:

Associated signs and symptoms:

Timing:

Exacerbating/ relieving factors:

Severity:

 

Medications: 

 

Allergies: 

 

Past Medical History (PMH):

 

Past Surgical History (PSH): 

 

Personal/Social History: 

 

Significant Family History:

 

Review of Systems: 

            General: 

            HEENT:

            Respiratory:

            Cardiovascular/Peripheral Vascular:

            Gastrointestinal:

            Genitourinary:

            Musculoskeletal:

            Neurological:

            Psychiatric:

            Skin/hair/nails: 

           Hematology:

           Lymphatics:

           Endocrinologic:

OBJECTIVE DATA: 

 

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:

Heart/Peripheral Vascular: 

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

 

Diagnostic results: 

 

Differential Diagnoses (5) For each diagnosis, provide supportive documentation with evidence-based guidelines.

(Detailed explanations please)