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A 41-year-old female presents with complaints of numbness, paresthesia, pain, and clumsiness in her right ulnar three digits, which were of gradual onset. The patient reports the symptoms seem to be related to activities that involve repetitive motion of her right arm. The patient's past medical history and family history is unremarkable, and recent radiographs found no evidence of cervical spine disease, lung disease, or the presence of a cervical rib or abnormally long C7 transverse process. The patient also recently underwent an electromyogram and nerve conduction velocity test, both of which proved negative. The patient denies any color changes in the right arm, swelling, trauma, or joint pain.

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What is your best working hypothesis?

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The best working hypothesis at this stage would be a condition involving neurovascular structures -- thoracic outlet syndrome.

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What is your differential diagnosis?

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The differential diagnosis for this patient should include, but not be limited to, an ulnar nerve entrapment, carpal tunnel syndrome, C8 cervical radiculopathy, intramedullary or extramedullary spinal cord processes (syringomyelia, glioma of the spinal cord etc.), Pancoast tumor, and pronator teres syndrome.

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The physical examination revealed the following findings:

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  • Forward head posture with rounded shoulders.
  • Slight atrophy of the right interossei and the hypothenar eminences.
  • Hypertrophy of the pectoralis major, pectoralis minor, and bilateral scalene muscles.
  • Patient demonstrates a non-diaphragmatic breathing pattern.
  • Normal range of motion and strength throughout bilateral upper extremities.
  • Decreased sensation to light touch in the proximal and middle portions of the medial area of the right forearm.
  • Normal deep tendon reflexes bilaterally.
  • Negative Tinel sign at right elbow.
  • All special tests negative except for positive hyperabduction maneuver.

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Following the findings from the physical examination, what is your best working hypothesis?

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A diagnosis of thoracic outlet syndrome could be made at this stage.

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Describe the pertinent anatomy involved with thoracic outlet syndrome.

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Which of the two sexes has a higher incidence of this condition?

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What congenital factors can predispose a patient for TOS?

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What are the most common peripheral nerve injuries that affect the shoulder region?

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What is a ‘stinger’ or ‘burner’?

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Having made the provisional diagnosis, what will be your intervention?

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In order of priority, what will be the goals of your intervention?

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