advanced health assessment

CASE STUDY: Numbness and Pain   

Patient Information:  

CK, 47, Female, Caucasian  

S.  

CC:  numbness and pain in the right wrist  

HPI: 47-year-old Caucasian obese female presents to the clinic with reports of right wrist pain, 6/10 with tingling and numbness in the thumb, index, and middle finger for 2weeks. The patient reports she is a hairdresser for the last 20 years and expressed frustration because the pain causes her to drop her work tools. Pt denies associated signs and symptoms. The patient stated she was at work when the pain, tingling, and numbness occurred, and the pain often wakes her up at night. The patient reports that she usually “shake out” her hand and wear a splint she got over the counter to relieve symptoms. Reports doing several activities with her hand at work causes more pain.    

Current Medications:   

DM type 2, metformin 500mg BID for two years but self-discontinued one year ago, “I didn’t feel I had diabetes.”  

Multivitamin daily for 20 years.    

Allergies: denies medication, food, and environmental allergies   

PMHx: immunization up to date, last tetanus five years ago when she stepped on a nail at work. Diagnosis in 2010 with diabetes type 2. hospitalized last year for pneumonia for three days. No major surgeries past major illnesses and surgeries.   

Soc Hx: works at a salon as a hairdresser for 20 years, enjoys reading and watching television. Married with one adult child. Denies tobacco use and reports to drinking wine with dinner or weekends to relax. Denies any other drug use. Patient reports wearing a safety belt while driving, denies exercise and described diet as “steak and potatoes.”,   

Fam Hx:  

Mother died three years ago from DM  

Father died in car accidents at age 59 ten years ago  

Grandparents both deceased before the patient was born.   

One brother who is healthy with no known illnesses  

Adult child is obese with borderline diabetes.   

ROS:   

GENERAL: Denies weight loss, fever, chills, fatigue, +weakness in the right hand.  

SKIN: denies rash or itching, denies open sores or wounds.  

CARDIOVASCULAR:  denies chest pain, chest pressure or chest discomfort. denies palpitations, edema.  

RESPIRATORY:  denies shortness of breath, cough or sputum, dyspnea on exertion, night sweats, exposure to TB.  

NEUROLOGICAL:  + reports numbness and tingling to thumb index and middle fingers on the right hand. Denies headache, dizziness, syncope, paralysis, ataxia, No change in bowel or bladder control.  

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.  

O.  

Physical exam:   

Vitals 132/80, 76, 16, 37.6c, 98%  

General: alert and oriented x4, cooperative, does not appear to be in acute distress, good posture while sitting, steady gait when ambulating, good historian.   

Skin: Skin is warm, dry, and intact   

Respiratory: symmetric, no visible abnormal findings, no use of accessory muscles in breathing, breath sounds CTA in all lobes.   

Cardiovascular: Heart rate regular rate and rhythm, S1 and S2 heard, no extra heart sounds heard, distal pulses are 2+ bilaterally, no edema noted, normal hair distribution in legs.   

Musculoskeletal- full ROM in the left upper extremity. Limited range of motion to the right upper extremity. Right weakened thumb abduction, hypalgesia  

Neurological: alert, attentive, and oriented; speech clear & fluent with reasonable comprehension; able to provide a clear account of historical and recent events. Motor- Motor: normal bulk, tone, and strength 5/5 left 4/5 right hand. Sensory: vibration felt in toes and fingers bilaterally; pinprick intact in feet, pinprick intact in hand bilaterally. Superficial pain sensation is not intact in right fingers. Reflexes: 2+ and symmetric at biceps, triceps, knees, and ankles; plantar responses flexor bilaterally. Coordination: normal fine finger movements, finger-nose-finger, and heel-knee-shin.  

Diagnostic results: - X-ray to r/o broken bone or sprain, A1C lab d/t p.t having DM which can damage nerves over time, + Phalen, +Tinel, manual carpal compression, and hand elevation tests  

A.  

Differential Diagnoses   

Carpal tunnel: is caused by compression of the median nerve. Several conditions have been linked to carpal tunnel such as obesity, female ages 40-60 is at higher risk, numbness and tingling of the thumb and radial fingers, clumsiness. a coexisting condition such as diabetes, and workplace factors that are often seen in hairdressers such as repetitive hand and wrist use, working with vibrating tools, prolonged extension, and flexion. (Kothari, 2019)  

Diabetes: Diabetic neuropathy is the result of nerve ischemia due to the direct effects of hyperglycemia on neurons, and intracellular metabolic changes that impair the function of nerves. (Brutsaert, 2019) This patient should be screened for diabetes, which could cause nerve pain, numbness, or decreased ability to feel pain. Tingling or burning, cramps, sensitivity to touch, and weakness. The patient in this case study reports all the signs and symptoms.  

C6 radiculopathy: sudden onset of severe unilateral neck pain. Associated with weakness and numbness predominantly of the dorsal aspect of the first and second fingers and lateral aspect of forearm. (Rainville, et al., 2017)  

Radial nerve compression syndrome: This syndrome affects the radial nerve, which extends the length of the arm. It can impact the wrist, hand, and finger function. It is more common in women between the age of 30-50. According to Moradi, Ebrahimzadeh, and Jupiter (2015), It occurs from intermittent compression on the radial nerve from the radial head to the inferior border of the supinator muscle, without apparent extensor muscle weakness. The authors noted that the exact site of pain and weakness of the third finger and wrist extension are valuable physical exams to diagnosis. (Moradi, Ebrahimzadeh & Jupiter, 2015)  

Anterior Interosseous Nerve Syndrome: is a motor branch from the Median nerve and runs deep in the forearm along with the anterior interosseous artery. It innervates three muscles in the forearm and five muscle in hand, over time can affect the joints of the thumb, and joints at the 2nd and 3rd digits if not diagnosed correctly. According to Aljawder, Faqi, Mohamed, and Alkhalifa (2016) On physical examination, the Pinch Grip test is positive where patients will not be able to demonstrate the “OK” sign, instead of clamping the sheet between an extended thumb and index finger 

P: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 

References 

Aljawder, A., Faqi, M. K., Mohamed, A., & Alkhalifa, F. (2016). Anterior interosseous nerve syndrome diagnosis and intraoperative findings: A case report. International journal of surgery case reports, 21, 44–47. doi:10.1016/j.ijscr.2016.02.021  

Brutsaert, E. F. (2019). Complications of Diabetes Mellitus - Endocrine and Metabolic Disorders. Retrieved from https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/complications-of-diabetes-mellitus?query=Compression neuropathy  

Kothari, M. J. (2019). Carpal tunnel syndrome: Etiology and epidemiology. Retrieved from https://www.uptodate.com/contents/carpal-tunnel-syndrome-etiology-and-epidemiology?source=autocomplete&index=0~1&search=carp  

Moradi, A., Ebrahimzadeh, M. H., & Jupiter, J. B. (2015). Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. The archives of bone and joint surgery, 3(3), 156–162. 

Rainville, J., Joyce, A. A., Laxer, E., Pena, E., Kim, D., Milam, R. A., & Carkner, E. (2017, October 15). Comparison of Symptoms from C6 and C7 Radiculopathy. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28767636