SOAP Note Chapter 4 Employee Health Visit #1 Terri Popoulis, NP Patient: Brett Jarvey 1/10/16 SUBJECTIVE - Pain a

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SOAP Note Chapter 4
Employee Health Visit #1 Terri Popoulis, NP
Patient: Brett Jarvey 1/10/16
SUBJECTIVE
- Pain and tingling in fingers, radiating up forearms, ongoing
for a month
- Worse after spending time on computer and after sleep
OBJECTIVE
- 23-year-old male
- Computer use 8–10 hours daily for work and recreation
- Rests wrists on keyboard when at computer
ASSESSMENT
- Carpal tunnel syndrome
PLAN
- Suggest improved ergonomics for work space
- Suggest NSAIDs (non-steroidal anti-inflammatory drugs, such as
ibuprofen)
- Give information on myofascial release
- Give information on carpal tunnel release
Questions: 1. What causes the symptoms of
carpal tunnel syndrome?
2. What diagnostic procedure is used to evaluate joint mobility
and muscle strength?
3. Which of the nonsurgical planned interventions will help
reduce the strain and stress that causes carpal tunnel
syndrome?