A 42-year-old woman presents with complaints of paresthesias(tingling and lately burning) and occasional pain and numbness in the right thumb, index, and middle fingers. Symptoms were initially intermittent, but becoming more constant, and the pain now often wakes her at night. In addition, recently she has noticed a loss of grip strength and has dropped objects on occasion. Onset was gradual, and symptoms worsening. She first saw her family physician 3 months ago for the numbness and tingling. The patient is a check-out clerk at a local grocery store. She is right-handed; BMI is 40.
On physical examination, sensory testing shows diminished touch and vibration sensation, and decreased two-point discrimination on the palmar surface of the thumb, and index, middle, and radial half of the ring fingers. Phalen and Tinel tests are positive. Thumb abduction, flexion, and opposition strength are only 4/5. Nerve conduction test done last week shows decreased nerve conduction velocity of the median nerve across the right wrist.