Diagnosing Numbness and Pain in Wrist and Fingers

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Table of Contents

Patient Information
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O
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References

Patient Information

Mrs. JM, 47, female, not identified

This paper aims to gather information from the patient to reveal the symptoms and review the body systems, which would allow for identifying differential diagnoses.

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CC (chief complaint): pain and numbness in wrist and fingers

HPI: A 47-year-old woman presents with right wrist pain, complaining about numbness and tingling in the index, middle, and thumb fingers during the last 2 weeks. The patient has obesity and states that her complaints make her drop her hair styling equipment since she cannot hold them.

Location: wrist and fingers
Onset: 2 weeks ago
Character: tingling, numbness
Associated signs and symptoms: frustration, reduced grip strength
Timing: the symptoms are more pronounced in the evening
Exacerbating/ relieving factors: overuse of the hand make the symptoms worse
Severity: 5/10 pain scale

Current Medications: Metformin to reduce weight (2,000 mg daily), Ibuprofen occasionally for headache treatment

Allergies: Aspirin causes anaphylaxis

PMHx: Influenza immunization (Fall 2020), Tetanus vaccination (8 years ago)

Soc Hx: Mrs. JM is married and works as a hair dresser for the last 15 years. She has 3 grown-up children, one of which lives with her, and others have their own families; all the family members live in the same city; their relationships are good. The patient drinks alcohol on weekends with her husband and friends. Mrs. JM’s living environment seems to be appropriate as she reports that she has awesome neighbors and a beautiful house.

Fam Hx: Hypertension and heart attacks are present among grandparents. The patient’s mother and father are alive and suffer from hypertension as well.

ROS

GENERAL: The patient states that she had no recent diseases, rapid weight loss or gain, and weakness, and fevers, but she recognizes that she has excessive weight.
HEENT: Eyes: Wears contact lenses for astigmatism and myopia. Ears, Nose, Throat: hearing is intact; the patient denies having running nose, sore throat, and congestion.
SKIN: Mrs. JM complains about age-related changes only (wrinkles, skin elasticity).
CARDIOVASCULAR: No palpitations and edema; the patient denies chest pain and any related symptoms.
RESPIRATORY: No issues regarding breathing.
GASTROINTESTINAL: The patient has frequent problems with constipation that is accompanied by pain in her intestines.
GENITOURINARY: No burning on urination, no pregnancy; last menstrual period 12/20/2020.
NEUROLOGICAL: Headache appears several times per week; numbness and tingling in the extremities (right wrist only). Bladder and bowel control is adequate.
MUSCULOSKELETAL: No arthritis, traumas, gut, or any muscle pain in the back.
HEMATOLOGIC: No bleeding disorders, blood transfusion, and clotting problems.
LYMPHATICS: Nodes are intact.
PSYCHIATRIC: Mrs. JM has a history of depression when her husband was severely traumatized in a car accident 5 years ago.
ENDOCRINOLOGIC: No endocrine disorders and hormonal therapies; the patient denies polyuria and polydipsia.
ALLERGIES: No asthma, eczema, or hives.

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Physical exam

Vital Signs: Vital signs: B/P 140/80, right arm, sitting; P 80 (regular); T 98.1 orally; RR 16; Wt: 245 lbs; Ht: 5’9; BMI 36

GENERAL: The patient is alert and oriented; seems to be mildly uncomfortable and anxious because she cannot yet understand her current condition.
NEUROLOGICAL: The patient is frustrated yet well-oriented (answers all the questions with understanding); her reflexes are symmetric; she is able to maintain balance with closed eyes.
MUSCULOSKELETAL: Numbness and tingling on the right wrist and three fingers only ().

Diagnostic results

Carpal tunnel compression test (Durkan’s test): the compression of the right wrist in the area of the median nerve passage within 30 seconds causes numbness and pain in half of the fingers of the hand, which means that the test is positive (Padua et al., 2016).

Tinel test: the tapping with a neurological hammer on the right wrist (over the place where the median nerve passes) causes a tingling sensation in the fingers and radiation of pain to the fingers (Vahed et al., 2018). In this patient, pain is not felt in the tapping area, but tingling is present.

Ultrasound of the right wrist: It is the most widespread peripheral nerve entrapment (Vahed et al., 2018). The ultrasound revealed the disappearance of median nerve areas in the right wrist of the patient, as well as hypo echogenicity of the involved nerve, which points to the carpal tunnel syndrome.

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Differential Diagnoses

Carpal tunnel syndrome. It is quite common in women between the ages of 30 and 50. The risk factors include rheumatoid arthritis or other types of wrist arthritis. According to Padua et al. (2016), the work that requires multiple flexion and extension movements in the wrist plays a role. The symptoms of carpal tunnel syndrome include pain in the arm and wrist, which is characterized by tingling and numbness and usually distributed along the median nerve, but possibly involving the entire arm (Padua et al., 2016).
Arthritis of the carpometacarpal (CMC) joint. In this pathology, the articular cartilage between the first metacarpal bone and the trapezium bone is damaged. Constant pain, inflammation, and stiffness at the base of the thumb are the main symptoms (Donato et al., 2019). Mrs. JM lacks a characteristic manifestation of arthritis that is pain during rotation and pressure of the first metacarpal bone towards the wrist (Donato et al., 2019). During this movement, the patient does not feel unpleasant sensations of friction between bone and bone.
Cervical radiculopathy (C6). In this case, reflex, sensory, and motor changes are associated with neck pain, while, in carpal tunnel syndrome, these changes are limited to distal manifestations, which is characteristic for the given patient (Thoomes et al., 2018).
Diabetic polyneuropathy. It is usually a bilateral, symmetrical process involving other nerves (not just the median). The peripheral nervous system is affected, namely, the nerves that go to the trunk, limbs, and head. Since the loss of skin sensitivity to temperature and night pains are not mentioned by the patient, quantitative sensory testing is necessary to exclude this diagnosis. This method becomes popular globally as it allows accurately determining the state of the sensory nerves, taking into account the individual characteristics of the patient (Ponirakis et al., 2016).
Flexor carpi radialis tenosynovitis. As stated by Bolles et al. (2016), this disease clinically mimics carpal tunnel syndrome. However, it also presents some swelling on the back of the wrist joint, which is absent in this patient. Differential diagnosis is carried out through several sessions of ultrasound and controlling laboratory tests.

Primary diagnosis: Carpal tunnel syndrome.

To conclude, this SOAP analysis shows that Mrs. JM’s primary diagnosis is carpal tunnel syndrome, which was established based on her complaints, objective examination, and diagnostic tests. The review of the relevant literature allows for creating a list of differential diagnoses that should be taken into account while treating the patient and monitoring the progress and future symptoms. Mrs. JM should be clearly explained about her diagnosis and its future manifestations, while the risk factors, such as obesity, her profession, and family history, should also be clarified, which is important to address the patients’ frustration and anxiety about her health.

References

Bolles, C. L., Abdella, A., & Battaglia, P. J. (2020). Flexor carpi radialis tenosynovitis mimicking carpal tunnel syndrome diagnosed and monitored with ultrasound: Case report. SN Comprehensive Clinical Medicine, 2, 797-801.

Donato, D., Abunimer, A. M., Abou-Al-Shaar, H., Willcockson, J., Frazer, L., & Mahan, M. A. (2019). First carpometacarpal joint denervation for primary osteoarthritis: Technique and outcomes. World Neurosurgery, 122, 1374-1380.

Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C.,… & Hobson-Webb, L. D. (2016). Carpal tunnel syndrome: Clinical features, diagnosis, and management. The Lancet Neurology, 15(12), 1273-1284.

Ponirakis, G., Odriozola, M. N., Odriozola, S., Petropoulos, I. N., Azmi, S., Fadavi, H.,… & Malik, R. A. (2016). NerveCheck: An inexpensive quantitative sensory testing device for patients with diabetic neuropathy. Diabetes Research and Clinical Practice, 113, 101-107.

Thoomes, E. J., van Geest, S., van der Windt, D. A., Falla, D., Verhagen, A. P., Koes, B. W.,… & Vleggeert-Lankamp, C. L. (2018). Value of physical tests in diagnosing cervical radiculopathy: A systematic review. The Spine Journal, 18(1), 179-189.

Vahed, L. K., Arianpur, A., Gharedaghi, M., & Rezaei, H. (2018). Ultrasound as a diagnostic tool in the investigation of patients with carpal tunnel syndrome. European Journal of Translational Myology, 28(2), 193-197.

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