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.
Based on the history and systems review do you agree with the physician’s diagnosis for this patient?
The patient history and system review seem to indicate a diagnosis of carpal tunnel syndrome, or median nerve entrapment.
List those factors mentioned in the history and systems review that help confirm your diagnosis.
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.
What are some of the diagnoses characterized by symptoms in this distribution?
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
What does the history of the gradual onset and of repetitive activity tell you?
The history of the gradual onset and of repetitive activity point to an overuse syndrome.
What additional questions would you ask to help rule out referral of pain from the cervical and thoracic spine?
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.
What additional questions would you ask to help rule out referral of pain from the shoulder or elbow?
Questions to help rule out referral of pain from the shoulder or elbow could include what the shoulder or elbow motions ...