| | CARAPL TUNNEL SYNDROME (HAND PAIN)
Doorway information about patient
The patient is a 41 -year-old woman who comes to the clinic with hand pain.
Vitals signs
. Temperature : 37’C
. Blood pressure : 126/80 mmHg
, Heart rate : 72/ min
. Respirations : 12/ min
Approach to the patient
Evaluation of hand symptoms should address 2 interrelated aspects:
. The symptoms itself (eg, pain , stiffness )
. The effect on fiction , including , occupational function
Begin by inquiring about the pain’s location (eg, joints , fingertips ) . quality ( eg, aching , burning ), severity , onset. duration , course over time , triggering/modifying factors , context (eg, occupation , prior musculoskeletal disorder ) , and associated symptom( eg , swelling ).
Chronic orthopedic disorders are common ,,and you may encounter a patient who has characteristic findings of a certain condition (eg- Heberden nodes of osteoarthritis-) but whose pain is actually due to unrelated case (eg, -Raynaud phenomenon-)
Different diagnosis
The diagnosis should first note any trauma that might indicated a fracture , sprain , or ligament avulsion . For atraumatic pain , the differential diagnosis is strongly influenced by location :
. Osteoarthritis typically affects the proximal and distal interphalangeal joints.
. Rheumatoid arthritis predominantly affects the wrist and metacarpiphalangeal joints .
. Carpal tunnel syndrome affects the palm and planar aspect of the first 3 or 4 digits.
. Ulnar neuropathy affects the medial wrist , hand and fifth digit,
. De Quervain tenosynovitis causes pain at the base of the thumb.
Associated symptoms also are helpful in the diagnosis . for example , joints swelling and prolonged morning stiffness suggest in inflammatory arthritis.
HISTORY AND PHYSICAL EXAMINATION
In addition to a general medical history , the following list some of the mist important questions to ask a patient with hand pain.
History
History of present illness
. Please tell me about your pain
. When did you first noticed the pain ?
. Can you point to where the pain is ?
. How dose the pain feel(eg, sharp , achy , burning )?
. How bad dose the pain get ? is there anything that makes it worse?
. Is the pain always present , or dose it come & go ?
. Is it getting better or worse overtime?
. Have you noticed swelling or stiffness in the joints ? How long does the stiffness last?
. is there numbness or weakness in your hand ?
. How are you doing with daily activities at home or at work ? Have you had to change your activities?
Past medical history
. Have you had bone , muscle , or joint disorders in the past?
. Have you had significant trauma?
Medications/allergies
. Are you taking any medications , especially pain medications ?
Social history
. What kind of work do(did) you do?
. Is anyone available at home to help you with normal activities , such as driving or housework?
Physical examination in orthopedic disorders benefits form having a broad selection of well-validated maneuvers (eg, -Phalen test - carpal tunnel syndrome, -Finkelstein maneuver for de Quervain tenosynovitis ) In most cases , you should examine the joints immediately above the below the symptomatic area to avoid missing additional injuries.
physical examination
General
. Note body habits ,gaits & posture.
Neck
. Note range of motion , deformities , or tenderness.
Cardiovascular
. Examine pulses; radial , ulnar , digital (if possible)
Musculoskeletal
. Examine elbow , first & digits : range of motion , swelling , deformities , tenderness.
. Palpate anatomic snuffbox (especially if trauma is present ).
. Note atrophy of hand muscles (eg , thenar eminence , interosseus muscles)
Neurologic
. Check upper extremity reflexes.
. Assess light touch sensation.
. Assess motor strength (eg, grip strength)
Coshing the encounter
During the wrap-up discussion , allow the patient to express their concerns and ask questions regarding their fictional limitations . Specific workplace modifications need not be discussed , but a discussion of functions; status os important for understanding the overall impact of the disorder . In addition , a patient who is unable to perform household or occupational tasks may warrant a more aggressive workup than a patient who is not limited by the symptoms.
Diagnostic studies
Subacute overuse injuries (eg, de Quervain tenosynovitis ) or conditions with pathognomonic examination findings (eg,palmar contracture ) may not need any diagnostic tests . If no testing is needed m write , “ No studies indicated “ in the Diagnostic studies section of the patient note.
- Inflammatory markers - (eg , erythrocyte sedimentation rate or c-reactive protein)can gauge disease activity in systemic inflammatory disorders (eg , rheumatoid arthritis) . - Serologic markers - (eg, cyclic citrullinated peptide antibody) can also be considered ; markers with high sensitivity (eg , antinuclear antibody) are ordered before less sensitive but more specific markers (eg, anti-double-stranded DNA antibody).Also , consider screening for metabolic disorder that might contribute to the condition (eg, hypothyroidism in carpal tunnel syndrome).
Most patients with trauma or arthritic symptoms should have a plain film x-Ray . Advanced imaging ( eg, MRI ) is usually considered only of the X -ray is non diagnostic.
Electrodiagnostic studies can confirm compressive neuropathies (eg, carpal tunnel syndrome) ,but are not usually ordered in the initial evaluation unless evidence of significant neurologic compromise (eg thenar atrophy and weakness) is present.
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2018/05/24 09:52pm 
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