SOAP NOTE
Patient: Joe Examiner: Ashley Bowen
Date of Injury: 3/12/05-4/12/05 (On-going) Date of Evaluation: 4/12/05
Area of Injury: R wrist
Subjective
History: 40 y.o. male golfer. Pt. stated that he did not get a direct blow to the
Wrist but that the problem has been ongoing. C/o pain in wrist c numbness down into the hand (middle & ring fingers). Pt. stated that pain and numbness increase at night & he would wake up c a numb hand. Pain rating at night is 6/10 & during that day it is 2/10. No h/o previous injury to the R wrist. Pt. also stated that he does a lot of typing at his job and the pain and numbness has been an ongoing problem, getting worse c time. He has not done anything to help treat his wrist & has not seen any doctors for it. Also, flexion & extension of the wrist was a little bit painful.
Objective
Observation: Pt. was point tender over carpal tunnel on R wrist w/o crepitation. There was a little bit of swelling in the wrist but not a whole lot. No obvious deformity was found, however, the R thenar eminence was smaller due to atrophy of the muscles.
PROM/AROM: AROM: Wrist Flexion: 83 Finger flexion(MCP): 70
Wrist Extension: 87 Finger extension(MCP):43
Wrist radial deviation: 20 Finger abduction: 25
Wrist ulnar deviation: 30 Finger adduction: 23
PROM: Wrist Flexion: 85 Finger flexion(MCP): 75
Wrist extension: 90 Finger extension(MCP): 47
Wrist radial deviation: 27 Finger abduction: 28
Wrist ulnar deviation: 33 Finger adduction: 25
RROM/MMT: Wrist flexion: 5/5 Finger adduction: 5/5
Wrist extension: 5/5 Thumb MP and IP flexion: 5/5
Finger MP flexion: 5/5 Thumb MP and IP extension: 5/5
Finger PIP and DIP flexion: 5/5 Thumb abduction: 5/5
Finger MP extension: 5/5 Thumb adduction: 5/5
Finger abduction: 5/5
Neurological Testing (Reflexes, dermatomes, myotomes):
Dermatomes- C6, C7, C8 (All WNL)
Reflexes- Biceps (C5-C6) (WNL)
Brachioradialis (C6) (WNL)
Triceps (C7) (WNL)
Cardiovascular Testing:
Radial artery: WNL
Ulnar artery: WNL
BP: 130/87
P: 70 BPM
Special Tests: Tinel’s sign at wrist (+), Phalens (+), EMG test showed deficit in the median nerve.
Assessment: Carpal tunnel syndrome of the R wrist
Plan: Pt. will manage pain c ultra sound & will be given a splint to sleep in at night. Pt. will also be ordered to stop activities that involve much use of the wrist (e.x. typing). A cortisone injection will be shot into the carpal tunnel and if that does not take surgery will be needed.
Short term goals: Manage pain c ultra sound pre-surgery and NSAIDS
Post surgery start light strengthening activities such as squeezing a stress ball several times qd
Long term goals: Regain ROM by going flexion/extension activities @ wrist at least once
qd and slowly add and increase resistance. Get pt. back to how they were pre-injury.
Re-evaluate on: 4/15/05 (before surgery), 4/25/05 (after surgery), and 4/27/05
ATS signature: LAT Signature:
Date: 4/12/06 Date:
