MN552 Unit 2 health history write-up example

Comprehensive Health History: Nocturnal Tingling of the Right Hand in a 41-Year-Old Dental Hygienist

[Student Name]

Purdue University Global

MN552: Advanced Health Assessment

Unit 2 Assignment

[Instructor Name]

[Date]

Composite patient written as a model document. No real patient, practice or clinician is described.

Identifying Data and Reliability

Patient: composite female, age 41, dental hygienist in a group general dentistry practice. Date of history: September 8, 2026. Setting: outpatient primary care visit, self-referred.

Source and reliability: The history was obtained from the patient, who is a clear and consistent historian with a detailed account of her symptoms. Medication doses were confirmed against her pharmacy list. The date of her thyroid diagnosis was confirmed from her prior clinic record. Each section below notes which of these sources it draws on, so a later reader can tell a reported detail from a verified one (Bickley et al., 2021).

Chief complaint (patient's words): "My right hand wakes me up at night, pins and needles in my thumb and the next two fingers."

History of Present Illness

Source: patient. The symptoms began in early July 2026. She first noticed tingling in the right thumb, index and middle fingers after a long clinic day, and within two weeks it began to wake her from sleep. It now wakes her about four nights a week, usually between 2 and 4 a.m. She describes it as "pins and needles, like my hand is asleep but worse." She does not feel it in the ring or little finger. At work it appears during long scaling appointments, especially when she treats lower molars with the wrist flexed, and it eases within a few minutes once she stops.

What relieves it: "I shake my hand hard, like I'm shaking water off, and after a minute it goes away." Holding her wrist straight in bed also helps. She has not tried a splint or any medication for it. She reports no weakness so far, has not dropped an instrument, and can still button clothing and hold a pen normally. She reports no pain in the forearm or elbow, no neck pain and no symptoms in the left hand. She rates the night tingling at 5 of 10 in intensity, and the loss of sleep, not the sensation itself, is what brought her in.

Past Medical History, Medications and Allergies

Source: patient and prior clinic record. Hypothyroidism, diagnosed in March 2014, managed with levothyroxine 88 mcg by mouth daily, last thyroid-stimulating hormone within range in April 2026 per record. One uncomplicated pregnancy with vaginal delivery in 2012. No history of diabetes, rheumatoid arthritis, kidney disease or wrist fracture. No surgeries. Immunizations reported as current, including influenza in October 2025.

Medications (confirmed with pharmacy list): levothyroxine 88 mcg daily; ibuprofen 200 mg as needed for headaches, about twice a month. No supplements.

Allergies: amoxicillin, with a generalized itchy rash in 2009. No latex allergy, which she confirms because she wears gloves all day.

Family History

Source: patient. Presented here in sentences; the three-generation genogram is attached. Mother, 68, has type 2 diabetes diagnosed at 55 and hypothyroidism. Father, 70, has hypertension. One brother, 44, is well. Maternal grandmother had rheumatoid arthritis diagnosed in her fifties and died at 81. Paternal grandfather died at 74 of a myocardial infarction. Her son, 14, is well. No family history of neuromuscular disease.

Social and Occupational History

Source: patient. She has worked as a dental hygienist for 17 years and currently works four days a week, seeing about eight patients a day. She estimates seven hours a day with a hand scaler or ultrasonic instrument in her right hand, with the wrist flexed and the fingers in a pinch grip during lower molar and lingual work. Her practice added two patient slots per day in May 2026, about two months before the symptoms began. Her work history carries the most specific detail in this record: the hours, the grip and the wrist position all describe the exposure that matches her symptoms. She lives with her husband and son, walks three times a week, and does not smoke. She drinks alcohol about twice a month, one glass of wine each time. She does not use other substances.

Sleep and daily function: She goes to bed at 10:30 p.m. and rises at 6 a.m. Before July she slept through most nights; she now wakes on about four nights a week and takes 20 to 30 minutes to fall asleep again after shaking her hand. She has stopped knitting, a hobby she did most evenings, because it brings on the tingling within about 15 minutes. She drives 25 minutes each way to work and has noticed tingling while holding the steering wheel at the top on longer drives.

Health maintenance: Source: patient and prior clinic record. Last Papanicolaou and human papillomavirus co-test in January 2025, reported normal. Last dental examination in June 2026. Last eye examination in 2024; she wears glasses for distance. She has not had a screening mammogram and is due to discuss timing. Seat belt use always; working smoke detectors at home; no firearms in the home.

Review of Systems

General: She reports no fever, no weight change and no night sweats; fatigue is related to disrupted sleep. Skin: She reports no rashes other than mild hand dryness from gloves. Head, eyes, ears, nose and throat: She reports no visual change and no neck swelling. Neck: She reports no neck pain or stiffness. Cardiovascular: She reports no chest pain and no palpitations. Respiratory: She reports no cough. Gastrointestinal: She reports no change in bowel habits. Genitourinary: She reports regular menstrual cycles. Musculoskeletal: She reports no joint swelling or morning stiffness in the hands and no elbow or shoulder pain. Neurologic: She reports tingling as described above, with no weakness, no symptoms in the left hand, no facial numbness and no balance problems. Endocrine: She reports no cold intolerance and no hair loss. Psychiatric: She reports low mood on days after poor sleep but no persistent sadness.

Where the Examination Should Go

The history directs the examination to four targets. First, the wrist and palm, including sensation in the thumb, index and middle fingers compared with the little finger, because her symptoms follow that distribution and are worsened by wrist flexion. Second, the thenar muscles, inspected for bulk and tested for strength, because she reports no weakness yet and a baseline is needed. Third, the cervical spine, examined for range of motion and tested for radicular symptoms, because a nerve root problem can also cause hand tingling, even though she reports no neck pain. Fourth, the thyroid gland, because hypothyroidism is associated with hand symptoms of this kind and her treatment status should be confirmed (Padua et al., 2016). Each target points back to a specific line in the history, and no diagnosis is recorded here (Ball et al., 2023).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C., Caliandro, P., & Hobson-Webb, L. D. (2016). Carpal tunnel syndrome: Clinical features, diagnosis, and management. The Lancet Neurology, 15(12), 1273-1284. https://doi.org/10.1016/S1474-4422(16)30231-9