Chief Complaint Sample is a year old female Her by robyniscrazy

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									Chief Complaint
   Sample is a 43 year old female. Her reason for visit is "Carpal Tunnel".
History of Present Illness
   She reported: Moderate hand or wrist pain at night. More than five times a day wrist pain.
   She denied: Lump on wrist.
   Location: She reported: Pain in left wrist. She denied: Joint pain in the right upper
   extremity.
   Duration: She reported: Average duration of wrist pain episode 10-60 minutes.
   Timing: She reported: Frequency of awakening at nigh with wrist pain is 2-3 times.
   Moderate daytime wrist pain.
Past, Family, and Social History
   Social History
       Activities for Daily Living
           History of: Mild difficulty of grasping and use of small objects. Mild difficulty
           buttoning clothes. Mild difficulty holding a book. Mild difficulty gripping a
           telephone. Mild difficulty opening jars. Mild difficulty with household chores. Mild
           difficulty carrying grocery bags. Mild difficulty bathing and dressing.
           She denied: Difficulty writing.
Review of Systems
   Neurological
       She reported: Moderate numbness in hand. Mild weakness of hand. Moderate dysesthesia
       in hand. Moderate numbness at night. Awakened two or three times at night in past two
       weeks with hand paresthesia.
Self-assessment Scales
   Title: Carpal Tunnel Syndrome Scale - Symptom Severity
   Description: 19-question test is scored from normal under 30 to 100 with the higher scores
   indicating greater severity of either symptoms or function in carpal tunnel syndrome.
   Patient Score: 54 - Moderate severity
   Scoring Key and Interpretation:
    20   - 30    :   Normal
    31   - 40    :   Mild severity
    41   - 60    :   Moderate severity
    61   - 100   :   Very severe
   Reference: Levine, Simmons, Koris, Daltroy, Hohl, A self-administered questionnaire for the
   assessment of severity of symptoms and functional status in carpal tunnel syndrome, The
   Journal of Bone and Joint Surgery, Vol 75A, No 11, November 1993, pp 1585-1591
   Title: Carpal Tunnel Syndrome Scale - Functional Status
   Description: 19-question test is scored from normal under 30 to 100 with the higher scores
   indicating greater severity of either symptoms or function in carpal tunnel syndrome.
   Patient Score: 40 - Mild severity
   Scoring Key and Interpretation:
    20   - 30    :   Normal
    31   - 40    :   Mild severity
    41   - 60    :   Moderate severity
    61   - 100   :   Very severe
   Reference: Levine, Simmons, Koris, Daltroy, Hohl, A self-administered questionnaire for the
   assessment of severity of symptoms and functional status in carpal tunnel syndrome, The
   Journal of Bone and Joint Surgery, Vol 75A, No 11, November 1993, pp 1585-1591

								
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