Henry Ford Studies Samples

MEDICATIONS:  Ibuprofen p.r.n.

CHIEF COMPLAINT:  Numbness and tingling in the fingers of the right hand.

HISTORY OF PRESENT ILLNESS:  Patient has had numbness and tingling in the fingers of her right hand digits 1 through 3 for several months.  Partial relief with the use of a splint provided by her primary care physician.  However, symptoms persist.  Occasionally awaken her at night.  Symptoms were felt primarily on the palmar aspect of the thumb, second and third digits of the right hand.  Patient occasionally has to shake her hand down to get relief.

REVIEW OF SYSTEMS:  There have been no problems with skin rash on sun exposure this summer.

PAST MEDICAL HISTORY:  Hidradenitis.

EXAMINATION:

VITAL SIGNS:  Weight is 166 pounds, blood pressure 115/72, with a pulse of 82, temperature 97.8.

MUSCULOSKELETAL:  Tinel’s sign is positive on the right hand.  No swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.  No pretibial edema.

IMPRESSION:  Carpal tunnel syndrome, right.

MEDICAL DECISION MAKING:  EMG requested.