Case 2: Numbness and Pain
A 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.
To prepare: With regard to the case study you were assigned:
•Review this week’s Learning Resources, and consider the insights they provide about the case study.
•Consider what history would be necessary to collect from the patient in the case study you were assigned.
•Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
•Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format.
Post 1 to 2 pages SOAP NOTE ON: A description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
•Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
◦Chapter 5, “Mental Status” (64-78)
◦Chapter 22, “Neurologic System” (pp. 544-580)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
◦Chapter 4, “Affective Changes” (pp. 33-46)
Bearden, S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.