Introduction
Assessment of the neurological system presents the nurse practitioner (NP) with numerous challenges because the symptoms are extensive and match several conditions. This paper looks at numbness and pain associated with wrist conditions.
History Taking
The NP must determine the patient’s definition of ‘numbness’ to uncover the specific sensation. The patient’s descriptions of numbness can be loss of sensitivity (anesthesia), vague sensations that present as a tingling (paresthesia), definite loss of sensitivity or an unpleasant burning feeling (dysesthesia). Other patients describe allodynia, a perception of harmless stimuli, as pain. Such a description can be due to nervous system trauma.
The NP must investigate features of numbness such as onset, precipitating factors and progression. The NP further examines the distribution of the numbness to find its borders and associated signs. During pain assessment, the NP also considers the attributes of pain such as location, severity, aggravating or relieving factors, onset, and duration (Dains, Baumann, & Scheibel, 2012). A history of trauma is also vital in establishing the cause of the symptoms.
Physical Examination
The NP must bear in mind that the presenting symptoms may pass from the hand, elbow, shoulder or cervical spine to the wrist (LeBlond, Brown, & DeGowin, 2009). The NP begins with an inspection of the palmar and dorsal wrist surfaces to observe any deformities of the wrist, hand and finger bones. The second step is observation of palm contours especially the thenar and hypothenar eminences for contractures.
The third step is palpation of the distal radius and ulna bones and the wrist groove. The NP further palpates the styloid bone and the anatomical muff box for signs of bulging and tenderness. Determining the range of motions in physical examination of the wrist is crucial and involves flexion, extension, adduction, and abduction of the hand and wrist. The NP should also assess wrist muscles for fatigue, strength and weakness. In patients who report irregularities, the NP must give the characteristics of the irregularities (Ball, Dains, Flynn, Solomon, & Stewart, 2014).
During physical assessment, the NP performs Tinel’s test, which is positive if the patient reports a tingling sensation in the fingers. The NP also performs Phalen’s test that comes out positive if the client reports pain, numbness or tingling within one minute of wrist flexion. Anteroposterior drawer tests of the wrist, slide guide and shear tests are useful exercises in determining wrist joint movements (LeBlond et al., 2009).
Diagnostic Tests
After physical examination, the NP may perform electromyography to determine skeletal muscle strength. Nerve conduction velocity tests help the NP determine the speed of electrical impulse conduction by the median, radial and ulna nerves. If the patient has an underlying chronic illness, the NP should consider laboratory investigations for erythrocyte sedimentation rate (ESR) and thyroid function tests. The presence of inflammatory diseases involves hematologic studies of inflammatory signs like leukocytosis. Imaging studies include X-rays, ultrasonography, computed tomography and magnetic resonance (Mahlknecht et al., 2010).
Differential Diagnoses
The first differential diagnosis for the patient is carpal tunnel syndrome (CTS), which results from median nerve compression as it passes through the carpal tunnel in the wrist. The second differential diagnosis is cervical spondylosis and cervical disc herniation, which are age-related conditions that involve wear and tear of the spinal disks.
The third differential diagnosis for the patient is thenar atrophy. Thenar atrophy is wasting of the muscles, which weakens them leading to disfiguring of the hand. The fourth differential diagnosis is peripheral neuropathy which involves damage to the peripheral nerves, which interlink to innervate the arm, forearm, wrist, and hand.
The fifth differential diagnosis is a brachial plexus lesion in the axilla. The plexus, which originates from the neck, controls the upper limb functions. Trauma to the lower level of the plexus causes Klumpke’s palsy leading to motion loss in the wrist and hand (Cash & Glass, 2014).
Conclusion
The nervous system has many interconnections hence injury to one region may manifest as pain at a different location. Therefore, motor function impairments require extensive physical examinations for accurate diagnosis.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Web.
Cash, C. J. & Glass, C. A. (2014). Family practice guidelines (3rd ed.). New York: Springer. Web.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby, Elsevier. Web.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw-Hill Medical. Web.
Magee, D. J. (2013). Orthopedic physical assessment (6th ed.). St. Louis: Elsevier Health Sciences. Web.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neuro-Degenerative Diseases, 7(5), 300–318. Web.