Patient Information
Name: J. Z. Age: 47 years old Sex: Female Race: African American
S
CC: “I am having uneasiness, tingling and numbness in my right wrist causing problems in holding and curling hair-styling tools and hair respectively at my work station”.
HPI: Patient (named J. Z) is a 47-year-old African American female who works as a hairstylist. She was concerned about pain in her right wrist with associated prickling and paralysis in the thumb, index, and middle fingers for the past two weeks. On a scale of 0-10, she reported a pain of 7/10 during relaxation and 9/10 when hairdressing. She had taken over-the-counter (OTC) medication of Ibuprofen 400mg. However, she stated that she was still waning and deteriorating.
Current Medications: Ibuprofen 600mg TDS for pain
Allergies: No history of allergies.
PIHx: Flu vaccine received in July 2019, Tdap received in May 2015, and Corona vaccine received in January 2021.
PMHx: Hypothyroidism, which was detected in 2016, and is being managed by Synthroid medication.
Soc Hx: Works for 12 hours a day per week as a contract hairstylist at the Blue Mambo Hair Salon located in Houston, Texas. She is negative for tobacco abuse.
Fam Hx: Both parents are alive and live in Houston, Texas. Father is 72 years old with a history of depression and high blood pressure. Mother is 64 years with hypothyroidism and diabetes. Her two younger siblings have not reported any significant health issues.
Past Surgical History: No past surgery reported
Sexual and Reproductive History: She is single, heterosexual, and divorced for 2 years. She is a mother of two from her past marriage.
ROS
GENERAL: Reports a 9/10 pain in the right wrist, which is prickly and numb. No reported weight loss and fever. Reports being fatigue.
HEENT: Reports no feeling of headache or dizziness. Denies blurry vision. Wear sunglasses. No report of nasal congestion or upper respiratory infection. Has a good sense of smell, vision, and hearing.
SKIN: No reports of such skin infections and symptoms as lesions, rashes, or itching. She reports discoloration on the cheeks and face.
CARDIOVASCULAR: No report of discomfort in the chest or palpitations.
RESPIRATORY: No reports of shortness of breath or coughs.
GASTROINTESTINAL: Has regular daily bowel movements and denies any abdominal discomfort.
GENITOURINARY: No report of hematuria or polyuria.
NEUROLOGICAL: No past spinal injury or injury to other parts of spinal cords.
MUSCULOSKELETAL: She reported that her right wrist pain is 7/10 during relaxation and 9/10 when working.
HEMATOLOGIC: No reports of bleeding or loss of blood.
ENDOCRINE: No reports of polydipsia, polyphagia, and polyuria. Have a regular menstrual cycle and no weight loss.
PSYCHIATRIC: She reports no changes in mood, anxiety, sadness, and suicidal thoughts.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ALLERGIES: No history of allergies.
O
VS: B/P 130/75, PR 74, oral Temp 37C0; Non-labored RR 19; SpO2: 97% RM air;
Ht: 5’ 6″ Wt: 88 Kgs. BMI: 34 (Overweight)
General: A&O x4, lovely, supportive and complaisant. Not in any severe pain when relaxing.
HEENT: Normocephalic. Proportioned facial structures. No conjunctiva erythema with PERRLA eyes. Wear sunglasses. The ears reported no discharge or swelling. Neck: Supple. Chest/Lungs: Breathings uniform and unlabored. Clear to no auscultation.
Skin: Pale on the face with normal tone on other parts of the body.
CV: Rate and rhythm are regular. No murmurs, brushes or racings.
Lungs: No coughs both dry and wet. The respiration is clear to auscultation.
Peripheral vascular: No peripheral edema,
Abdomen: Normal bowel sounds and movement.
Genitourinary: Had reported urge incontinence and compulsion.
Neurological: Alert and oriented x4. No balance deficit. Cranial nerves II to XXII are grossly intact.
Diagnostic Results
- Two-point discrimination: Reduced on R hand only over thumb, index and middle fingers. Superficial pain, stereognosis and graphesthesia tested normal bilaterally (Able to recognize moving objects).
- Tinel test: Reported positive RUE.
- Phalen’s test: Reported positive RUE with positive paresthesia in the R hand and middle fingers.
- Sensation reduced to right thumb and index finger.
- Lab tests: A1C (r/o diabetic neuropathy) and thyroid panel.
Physical Exam
- Phalen test: A positive Phalen test is also indicative of Carpal tunnel syndrome. In this case, the test is conducted by flexion of the wrist through a 90° in an unforced mode (Arab et al., 2018). A result of a feeling of such numbness as paresthesia and tingling of the median nerve are reminiscent of carpal tunnel syndrome.
- Tinel test: Tinel test is performed by using a tender thumping using a rubber hammer, which presses the median nerve in the affected parts of the carpals (Arab et al., 2018). If tingling occurs on the carpals because of force at the percussion tip, a positive result is noted.
- Stereognosis: This procedure is performed by offering a patient an identifiable object to be recognized by the sensation of touch or manipulation (Sivapathasundharam & Biswas, 2020). The incapacity to distinguish such objects through touch indicates the presence of a parietal lobe lesion.
- Two-point discrimination: This is a test conducted to determine sensory abnormalities. It involves testing fingertips and hands using such instruments as sterile clips or pins (Won et al., 2017). A reduction in the touch perception is an indication of carpal tunnel syndrome.
Diagnostic studies
- Nerve conduction studies: For this test, a sequence of superficial conductors is located at diverse sites along precise exterior nerves and stimulated at one location and recorded at various sites to establish electrical nerve conduction and signals (Kishner & Elliot, 2018).
- Ultrasound: Ultrasound scan is an analytical test, which uses high-frequency sound waves to generate films of bone and tissue, which are used to assess the median nerve for signs of carpal tunnel syndrome (Brown et al., 2017).
Differential Diagnoses
Carpal Tunnel Syndrome: The condition arises when the tunnel becomes constricted, leading to smooth tissues surrounding the flexor tendons inflaming because of the pressure of 20 to 30 mmHg on the median nerve (Brown et al., 2017). The disease is prevalent in women and adults ages greater than 30 years, whose tunnel and Phalen tests are positive (Brown et al, 2017). The signs of CTS are not limited to prickling, numbness, and burning sensations of the thumb, index, and ring fingers. This forms the primary diagnosis for patient J. Z.
Peripheral neuropathy (PN): PN is a nervous system disease resulting from the loss of such sensations of the nerves as motor and sensory sensations, a condition prevalent in diabetic type 2 patients (Mayo Foundation for Medical Education and Research [MFMER], 2019). The symptoms include numbness, cramping of the hands and feet, and tingling. However, since the conditions are only localized in the hands, it is unlikely that J. Z is suffering from PN.
De Quervain tenosynovitis: In this condition, most patients manifest a painful perception at the wrist with inflammation of the thumb (MFMER, 2020).
Fibromyalgia: Fibromyalgia is a condition associated with fatigue, insomnia, and muscle and joint pains, and common in patients with a history of mental illness such as depression. (National Institute of Neurological Disorders and Stroke [NIH], 2019).
Multiple sclerosis (M.S): MS is an autoimmune disease condition associated with steady but random development of swelling and disintegration of the myelin of the brain’s white matter, resulting in a diminished brain mass and congested conduction of nerve impulses (NIH, 2019).
Symptoms of muscle weakness, paresthesia, and cognitive changes are common in women of ages 20-40 years old.
References
Arab, A. A., Elmaghrabi. M. M., & Eltantawy, M. H. (2018). Carpal tunnel syndrome: Evaluation of its provocative clinical tests.Egyptian Journal of Neurosurgery, 33(14), 1-14. Web.
Brown, B, D., Roth, T. S., Gasner, K. A. (2017). Acute carpal tunnel syndrome after canine bite.Journal of the American Academy of Orthopaedic Surgeons, 1(9), 1-18. Web.
Kishner, S., & Elliot, L. (2018). Electromyography and nerve conduction studies. Medscape. Web.
Mayo Foundation for Medical Education and Research. (2019). Peripheral neuropathy. Mayo Clinic. Web.
Mayo Foundation for Medical Education and Research. (2020). De Quervain’s tenosynovitis. Mayo Clinic. Web.
National Institute of Neurological Disorders and Stroke. (2019). Multiple Sclerosis Information Page: What research is being done?Web.
Sivapathasundharam, B., & Biswas, P. G. (2020). Oral Stereognosis-A literature review. European Journal of Molecular & Clinical Medicine, 7(9), 1053-1063. Web.
Won, S., Kim. H., Kim. M., & Kim. K. (2017). Two-point discrimination values vary depending on test site, sex and test modality in the orofacial region: A preliminary study.Journal of Applied Oral Science, 25(4), 427-437. Web.