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A 49-year-old female secretary complains of insidious onset of right hand numbness and pain, which began about 5 weeks previously. The symptoms are felt mainly in the right index finger, especially when working at her computer at work, but also in her right thumb and middle finger after a day at work. The symptoms are also reported to be worse during the night and early morning. The patient has also noted a slight decrease in her grip strength, which prompted her to see a MD, who diagnosed carpal tunnel syndrome and prescribed PT, ibuprofen, vitamin B6, and a short course of diuretics. The patient denies any neck pain or history of previous symptoms or of diabetes mellitus. The patient is a full-time secretary at local community hospital for last 6 years. The patient was recently promoted which has meant an increase in computer work. The patient has an unremarkable medical and surgical history and has had no previous episodes.

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Based on the history and systems review do you agree with the physician’s diagnosis for this patient?

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The patient history and system review seem to indicate a diagnosis of carpal tunnel syndrome, or median nerve entrapment.

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List those factors mentioned in the history and systems review that help confirm your diagnosis.

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The factors that help confirm the diagnosis include the following cluster of signs and symptoms: insidious onset, the distribution of symptoms, the report of symptoms being worse at night and in the morning, and the report of decreased grip strength.

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What are some of the diagnoses characterized by symptoms in this distribution?

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Other diagnoses to consider include referral from the shoulder or elbow, cervical radiculitis,1 thoracic outlet syndrome, pronator syndrome,2 coronary artery ischemia, tendonitis, fibrositis, and wrist joint arthritis.3,4

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What does the history of the gradual onset and of repetitive activity tell you?

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The history of the gradual onset and of repetitive activity point to an overuse syndrome.

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What additional questions would you ask to help rule out referral of pain from the cervical and thoracic spine?

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Questions to help rule out referral of pain from the cervical and thoracic spine could include asking whether paresthesias occur with coughing or sneezing, or whether there is a pattern of motor or sensory disturbances outside of the territory of the median nerve.

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What additional questions would you ask to help rule out referral of pain from the shoulder or elbow?

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Questions to help rule out referral of pain from the shoulder or elbow could include what the shoulder or elbow motions ...

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