Week 4 Peer Response to SOAP Note Presentation

Responding to Miguel Garcia

Hello,

Your SOAP note presentation is thorough and enlightening. You did a great job assessing and diagnosing CTS in your 71-year-old male patient. Notably, the history taking, especially the onset without a specific incidence and the pattern of numbness in the median nerve distribution, is well concordant with the classic presentation. Also, the use of positive Tinel’s and Phalen’s signs, which are hallmark indicators of CTS, is commendable.

In addition, one thing that may have given further delineation was the patient’s grip strength. Indeed, the slight reduction in grip strength is either due to early motor involvement or muscle atrophy. Accordingly, this is an area where you could closely follow up, especially in light of the patient’s resistance to surgical intervention. I would also recommend some further strength testing and even measurement of hand dynamometry for an objective verdict on grip strength recommended by Núñez-Cortés et al. (2022). In addition, taking into consideration that this was a chronic smoker patient, I share your concern about smoking cessation. According to the findings by Hulkkonen et al. (2019), smoking compromises microvascular circulation, which might further exacerbate nerve compression and retard recovery.

Notably, while largely in agreement with your conservative management approach, including wrist splinting and stretching exercises, other options like corticosteroid injections may also be considered when the patient does not respond to initial treatment. Corticosteroids have been of significant short-term relief in controlled studies, especially in patients with moderate CTS who are not ready for surgery (Karjalanen et al., 2022). Generally, the presented management plan was extensive, and your patient education was considerate and well-presented.

References

Hulkkonen, S., Auvinen, J., Miettunen, J., Karppinen, J., & Ryhänen, J. (2019). Smoking as risk factor for carpal tunnel syndrome: A birth cohort study. Muscle & Nerve, 60(3), 299–304. https://doi.org/10.1002/mus.26627

Karjalanen, T., Raatikainen, S., Jaatinen, K., & Lusa, V. (2022). Update on Efficacy of Conservative Treatments for Carpal Tunnel Syndrome. Journal of Clinical Medicine, 11(4), 950. https://doi.org/10.3390/jcm11040950

Núñez-Cortés, R., Cruz, B. del P., Gallardo-Gómez, D., Calatayud, J., Cruz-Montecinos, C., López-Gil, J. F., & López-Bueno, R. (2022). Handgrip strength measurement protocols for all-cause and cause-specific mortality outcomes in more than 3 million participants: A systematic review and meta-regression analysis. Clinical Nutrition, 41(11), 2473–2489. https://doi.org/10.1016/j.clnu.2022.09.006

Responding to Alison Wright

Hello,

Thank you for sharing a comprehensive account of the case of the 17-month-old girl who had hand, foot, and mouth disease. The history and physical examination, as well as the symptom courses for HFMD, such as fever and oral ulcers, are detailed. The presentation also shows the careful consideration of your differential diagnoses that needed to be ruled out, including viral warts, fifth disease, and strep throat, both clinically and through the negative rapid strep test.

In addition, it would be further important to examine the differential diagnosis of herpangina. While it also contains oral ulcers and fever, herpangina typically does not include the characteristic hand and foot lesions associated with HFMD. Considering herpangina in the differential may have been helpful, given that this patient did not have a rash of the hands or feet at the time of your examination. However, I agree that HFMD is likely given the symptom progression, as pointed out by Corsino et al. (2020). Your management plan was appropriate and thoughtful with regard to advising the mother to watch for dehydration and giving symptomatic care measures with acetaminophen and ibuprofen.

Lastly, regarding pain management, I recommend administering topical oral analgesics to ease the discomfort so that it is less painful for the child to eat and drink. According to Légeret and Furlano (2021), topical oral anesthetics could relieve pain in interdigital ulcers. Also, education on hygiene practices and preventing the spread of HFMD among other children and pregnant women is commendable; it is a critical teaching point because complications in pregnant women might occur.

References

Corsino, C. B., Ali, R., & Linklater, D. R. (2020). Herpangina. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507792/

Légeret, C., & Furlano, R. (2021). Oral ulcers in children- A clinical narrative overview. Italian Journal of Pediatrics, 47(1). https://doi.org/10.1186/s13052-021-01097-2

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PEER RESPONSE 1:

BY: MIGUEL GARCIA

Video link: https://www.youtube.com/watch?v=QZ5CHz0Q6dE

TRANSCRIPT:

0:00

hello everyone my name is Miguel Sierra

0:02

Garcia I’m an practitioner student of

0:04

United State University uh uh currently

0:08

in the FMP 597 I want to present a case

0:11

of a patient that I treated this week

0:14

this is a initial RM a 71 years old

0:17

Caucasian male Who present to the clinic

0:19

with only complaint of pain and nness in

0:22

his right hand primarily the thumbs

0:25

index and middle finger for the past six

0:27

month the patient report gradual on set

0:30

without a specific tigging event the

0:33

pain is described as tingling and T

0:36

nness with greater intensity at n

0:40

located in the Palmer area of the right

0:42

wrist and radiating to the finger

0:44

mentioned above the duration of is

0:47

continued Ultra with a fluctuation uh in

0:51

intensity the patient has noted that uh

0:53

symptom are aggravated with a flexion in

0:56

the right wrist and activity that

0:58

require a firm grip

1:00

he has no identified factor that uh

1:03

significantly alleviated his uh syndome

1:06

and admit that he had not receive a

1:08

prior treatment he rate the pain a three

1:11

of 10 and describ a slight uh decrease

1:14

in grip strength with his right hand uh

1:18

the patient has a hypertension

1:20

controlled with Losartan he has full

1:23

check out was 14 months ago with a

1:26

normal colonoscopy in February 2022 and

1:29

up to dat vaccination no family history

1:32

reveal to the current condition he is a

1:35

longtime smoker a pack a day for 50 year

1:38

he has been with for three years live

1:41

alone and maintain a Balan diet but does

1:45

little physical activity dedicating his

1:47

free time to craft the review system was

1:51

negative except for uh the muscular

1:53

skeletal and neurological system the

1:56

patient report pain and nness in his

1:58

right hand and G radiating to the uh

2:01

thumb index and middle finger uh with a

2:04

slight decrease in grip strength and

2:06

worsening at night there are no other

2:08

significant constitutional

2:10

cardiovascular pulmonary or neurological

2:13

symptoms the patient has a stable Vital

2:16

sign the physical examination reveal an

2:18

individual in good General condition a

2:21

little overweight the cardiovascular and

2:23

Pulmonary examination or normal muscular

2:26

scal examination show a mild tenderness

2:29

in their right carpal tunnel uh

2:32

decreased strength in the right hand and

2:35

positive thiner and fent signs the

2:38

neurological examination reveal muscle

2:40

strength four or five in the right hand

2:43

with hypesthesia and parisia in the uh

2:47

distribution of the medial nerves while

2:50

the rest of the neurological examination

2:52

normal carpal tunel syndrome was

2:55

considered the most like uh diagnosis

2:58

due to the paresthesia in distribution

3:00

of the medial net with positive T Tino

3:03

and Fallen sign the curine ositis and

3:08

primary osteot tried of the right R were

3:11

ruled out du it to the distribution of

3:14

symptom and the absence of physical

3:16

finding compatible with this condition

3:19

uh the final diagnosis is a carpal tun

3:21

syndrome as part of the plan the patient

3:24

was intruded uh to perform an

3:26

electromyography and a nerve condition

3:29

study of the right hand to confirm the

3:31

diagnostic uh the American Academy of

3:34

orthopedic surgeons recommend n

3:36

reconduction study electrom myography in

3:39

the diagnosis of a carpal tunel syndrome

3:41

in 2024 a reference the patient was

3:45

recommended to we at a a r sping on the

3:48

right hand at n for four weeks to keep

3:52

the r in a neutral position and reduce

3:54

compression of the medial nerve he was

3:57

intruded uh to use AR compress on his

4:01

right uh wrist and perform hand and

4:04

wrist stretching exercise in carpal

4:07

tunnel syndrome it is recommended to

4:09

start conservative treatment with a

4:11

splint heat electrotherapy ultrasound

4:15

manual therapy and exercise as indicated

4:18

in the article titled carpal tun

4:20

Syndrome from 2019 it is it was

4:23

indicated to start a therapy with a

4:26

pregn on 20 migr daily orally uh since a

4:29

according to Genova and collaborator in

4:31

2020 is another reference that I use it

4:34

uh this medication improved the symptoms

4:36

and functionality of patient for at

4:39

least eight weeks uh he was advised to

4:42

avoid activity aggravating symptoms in

4:45

line with

4:47

Ericson

4:48

uh 2019 recommendations it’s another

4:52

reference uh the patient was educated

4:55

about the nature of his condition to

4:58

conservative treatment plan and the

5:00

importantance of avoiding activity that

5:03

aggravating symptoms such as a

5:05

repetitive touch or prolonged RIS

5:08

flection he was uh giving information

5:12

about ergonomics at home he was advised

5:14

to stop smoking and was ordered online

5:18

uh resour to quit this habit a followup

5:21

appointment was scheduled in one we to

5:25

elevate uh to evaluate the result of the

5:28

of of the indicated test that I

5:30

mentioned before a new appointment is uh

5:33

planned to be scheduled in four four

5:35

weeks to evaluate respond to treatment

5:38

and if there is no improvement referral

5:41

to an orthoped especially will be

5:43

considered that is very important I hope

5:47

all of you enjoy my video and one more

5:49

time thank you so much and have a great

5:52

uh afternoon

PEER RESPONSE 2:

BY: ALISON WRIGHT

VIDEO LINK: https://www.youtube.com/watch?v=dqQP-50U_YY

TRANSCRIPT:

hi my name is Alison Anderson this is my

0:03

soap note presentation on a patient that

0:05

I saw this week in clinicals so wa is a

0:09

17-month-old female came in today with

0:11

her mom um Mom stated my daughter woke

0:15

up with a blister on the end of her

0:16

tongue so mom also had reported she had

0:20

like an Associated fever for the past 24

0:22

hours has had increased irritability um

0:25

no nausea vomiting no sick contacts and

0:29

no injury to the the tongue um so she

0:31

was an only child didn’t go to like

0:33

daycare any like group activities where

0:35

other children could be around um and

0:37

she was sitting calmly on Mom’s lap and

0:39

no acute distress so no pertinent past

0:42

medical history no allergies no

0:45

medications immunizations were all up to

0:48

date um no pertinent past medical

0:50

history with the

0:52

family um no smoke exposure or any

0:55

social concerns on the review of

0:57

symptoms the only thing that was

0:59

positive was the recent fever for the

1:01

past 24 hours and Mom then stated that

1:04

she had a slight decrease in appetite

1:05

she was still eating and drinking um but

1:08

just not as much as she was Prior um

1:11

other than that um her Vital Signs so

1:15

heart rate was 118 blood pressure 91

1:18

over 49 her temp was 101.8 rectly 24

1:22

respirations 100% and her pain was a

1:25

four out of 10 on the flax scale height

1:27

and weight were good and appropriate for

1:28

her age and her

1:30

weight um no per no like recent Labs or

1:35

Radiology Imaging studies had been

1:37

recently done with her physical

1:39

assessment um her General and

1:42

constitutional was fine no apparent

1:44

distress she was well Grom not sick

1:46

appearing dressed appropriately for the

1:48

weather um on her hen T her she was

1:52

normos calic her pupils were equal round

1:54

reactive um her ears looked fine no

1:58

um and like no nasal drainage or

2:01

anything like that the only thing that

2:03

was abnormal um so was the ulcers on her

2:07

tongue so at first we just saw there was

2:09

an 8×4 mimer one on the tip of her

2:12

tongue roughly it was kind of hard to

2:14

measure for a 17-month-old

2:16

um and she was very sensitive to touch

2:19

with like any sort of mouth examination

2:21

so when we tried like putting a tongue

2:23

depressor in her mouth she like squalled

2:26

and like didn’t want us anywhere near

2:28

her mouth so you could really tell that

2:30

it was bothering her um her respirations

2:32

were fine lungs sounded great heart rate

2:36

regular rhythm um assessment wise

2:38

everything else was normal um

2:41

so our differentials were

2:45

a viral oral wart um but typically you

2:49

don’t

2:50

see um like the irritability and the

2:53

fever with that um fifth’s disease but

2:56

typically there’s like a rash all over

2:59

um or sixth disease and you’ll see like

3:00

the slap cheeks she didn’t have any of

3:03

that group a strep um it’s pretty

3:06

uncommon for a 17-month old to have

3:09

strep it’s not impossible um but

3:11

typically you see it in the age group

3:13

greater than three um so we went ahead

3:17

and did a rapid STP on her it was

3:19

negative we did go ahead and send out a

3:21

culture just to be on the safe side um

3:24

but this patient wasn’t having like that

3:26

sandpaper rash or um any like GI upset

3:29

or anything anything like that that’s

3:30

typically associated with strub throat

3:32

in

3:33

Pediatrics so the primary diagnosis of

3:35

hand foot and mouth disease was chosen

3:37

for this patient um based upon the

3:40

blisters on the tongue increased

3:42

durability fever and decreased appetite

3:46

so hand foot and mouth disease outbreaks

3:48

are more common in the fall um and they

3:51

don’t have to have I thought they had

3:53

have the rash on the hands the feet and

3:56

the mouth all at the same time for it to

3:58

be considered hand foot and mouth and it

4:00

doesn’t so this patient just had the

4:02

ulcers in her mouth she might later on

4:06

um have the outbreak and have blisters

4:09

or a rash on her hands and her feet so

4:11

we definitely did some education on how

4:13

like some symptoms might get worse

4:15

before it gets

4:16

better um but pretty much education was

4:19

just done that this is going to last

4:21

like 7 to 10 days um you can like we

4:24

told Mom you know continue to give

4:26

Tylenol um and Motrin weight based every

4:29

68 hours is needed for pain and fever um

4:32

keep giving the oral fluids make sure

4:34

that we keep her hydrated if there was

4:37

any concern for dehydration or she

4:38

stopped wanting to eat or drink bring

4:40

her back to the office or even to the ER

4:42

if we’re not seeing any like wet diapers

4:45

um but just a lot of education on like

4:48

how to prevent the spread of it and

4:49

keeping her away from pregnant

4:51

individuals and other children so um it

4:55

can actually cause impregnant

4:56

individuals like fetal demise so that

4:59

was a big teaching Point um also like

5:03

handwashing disinfecting things um other

5:07

than that just like when to follow up

5:09

and if newer worsan symptoms go to the

5:12

ER um but that was my patient for this

5:15

week let me know if you guys have any

5:16

feedback