Name: Moses Sinclair

 Pt. Encounter Number: 456789

Date: 06/1/2024

Age: 68

Sex: Male

SUBJECTIVE

CC:  

“I am having pain in my right hand for 3 months.”

HPI:  

Patient complains of right hand and wrist pain and weakness for 3 months ago. “It lasts all day but not constant pain.”  “It’s an achy pain and an elecrtrical shock feeling.” Patient states the more he uses his right hand, the more it aches. Rubbing his right hand helps with the pain a little and takes a Tylenol ES during the day helps a little as well.   The pain is “pretty bad” in the afternoon, patient states, 7 out 10 on severity.  

Medications: 

Patient taking OTC Tylenol ES at this time, denies any prescribed medications, herbs or supplements; past or present

Allergies: NKDA

Medication Intolerances: None

Past Medical History: None

Chronic Illnesses/Major traumas: None, Denies any major traumas.

Hospitalizations/Surgeries: None

Family History: Diabetes and Stroke runs in family; Father-age 91, alive, Type II Diabetes and on insulin; Mother-age 90, alive, had stroke 10 years ago when she was 80, doing well. Sister-passed away at age 67 due to heart disease.

Social History:

Patient is a carpenter.  Patient lives with his wife in a single-family home. Patient denies smoking, alcohol and drug use.  Patient is sexually active.   Patient is up-to-date with immunizations.  Patient hasn’t had any cancer screenings.

Review of Systems

General 

Denies weight change, fever, chills, night sweats.  Patient c/o fatigue, feeling more tired as of late

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, and edema

Skin

 Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Eyes

Denies corrective lenses, blurring, and visual changes of any kind

Gastrointestinal

Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ears

Denies ear pain, hearing loss, ringing in ears, and discharge

Genitourinary/Gynecological

Denies urgency, frequency burning, change in color of urine; sexually active, denies STDs

Nose/Mouth/Throat

Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Musculoskeletal

Denies back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis.

Complains of right hand and wrist pain and weakness, achy, “electrical shock” sensation

Breast

Denies lumps, bumps, or changes