CASE STUDY Numbness and Pain – A 47-year-old obese female complains of pain in her right wrist

Group 2: CASE STUDY: Numbness And Pain A 47-Year-Old Obese Female Complains Of Pain In Her Right Wrist

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

Week 9

You will be focused on Neurological Symptoms. Group 1 has Case study 1 and Group 2 Numbness and Pain. You have 2 required assignments for this Week.

Assignment 1:

To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least three possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

By Day 6 of Week 9

Submit your Assignment.

Numbness And Pain Case Study Sample Week 9

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Patient Information:

Initials: V.B. Age: 47 years Sex: Female Race: Caucasian S.

CC: “I have right wrist joint pain, and numbness and tingling sensation on the right-hand finger”

HPI: V.B. is a 47-year-old Caucasian female who presented with complaints of pain in the right wrist joint that is associated with numbness and tingling sensations in the thumb, index, and middle fingers for two weeks. The symptoms were of gradual onset, she rated the wrist pain at 2 when the wrist is immobile but increases to 6 on a scale of 0-10 when she is moving the joint.

The pain is described as aching and is extending proximally along the ventral side of the forearm, it is aggravated by repetitive movement of the joint especially when she is styling the hair, and is relieved by resting the joint and is also mildly relieved by taking over-the-counter ibuprofen. She reported that she is being frustrated by the symptoms since she is a hairstylist and the pain causes her to drop her hair styling tools.

Current Medication:

Oral ibuprofen 400 mg PRN Amlodipine 10 mg OD oral HCTZ 25 mg OD orally.

Allergies: She is allergic to Sulfa drugs but has no known food or environmental allergies.

PMHx: She is a known hypertensive on treatment but no surgical procedures history.

Soc Hx: She is a hairstylist who works in a local beauty spa. She has a history of occasional alcohol intake and cigarette smoking but she has no history of use of illicit drugs. She is married and lives with her husband and children. Her hobbies include singing and reading books.

Fam Hx: She Is the firstborn in a family of three, all her siblings are alive but the last born has schizophrenia. Her parents are both alive, her father is known hypertensive and he currently has cancer of the esophagus, and her mother has hypertension and diabetes. She is married with three children who are all alive and fine.

ROS

GENERAL: She denies fever, chills, weakness, recent weight changes, loss of appetite, and cold or heat intolerance.

HEENT: Head: She denies headache, head trauma, seizures, or dizziness. Eye: She denies eye pain, eye discharge, photophobia, visual loss, or blurring of vision. Ear: She denies ear discharge, ear pain, tinnitus, or loss of hearing. Nose: She denies sneezing, nasal blockage, nose bleeding, or running nose. Throat: She denies hoarseness of voice or difficulty in swallowing.

SKIN: She denies skin itchiness and rashes.

CARDIOVASCULAR: She denies palpitations, edema, shortness of breath, orthopnea, and nocturnal orthopnea

RESPIRATORY: She denies cough, difficulty in breathing, sputum production, or fast breathing.

GASTROINTESTINAL: She denies abdominal pains, nausea, loss of appetite, diarrhea, heartburn, or vomiting.

GENITOURINARY: She denies hematuria, dysuria, frequency, oliguria, burning sensation, incontinence, or vaginal discharge.

NEUROLOGICAL: She denies headache, syncope, paralysis, dizziness, ataxia, change of bladder or bowel control, but she has a history of numbness and tingling sensation of the thumb, index finger, and middle finger.

MUSCULOSKELETAL: She denies back pain, joint swelling, joint stiffness, and muscle pain but she has a history of right wrist joint pain.

HEMATOLOGIC: She denies anemia, easy bleeding, or easy bruising. LYMPHATICS: She denies Splenectomy and lymphadenopathy.

PSYCHIATRY: She denies anxiety, hallucinations, depression, sleep pattern changes, or homicide/suicide ideations.

ENDOCRINOLOGIC: She denies intolerance to heat or cold, sweating, polyuria, or polydipsia. ALLERGIES: She denies asthma, eczema, rhinitis, or hives.

Vital signs: BP- 135/87 mmHg, PR-87, RR-19, Temp- 98.1, SpO2-98% on room air, Ht-

5’11”, Wt- 153 lbs., BMI-21.3

General– She has a good body posture, is in a good nutritional status, is well-groomed, normal, has good communication skills, is cooperative, and maintains eye contact. She is alert, oriented to time, place, and person.

HEENT: Head: On examination, normocephalic, atraumatic, no scars, normal hair distribution, and no swellings. On palpation, there are no masses and no tenderness. Eye: On inspection, there is no excessive tearing, no eye discharge, and the sclera and conjunctiva are clear. His extraocular movements are intact, normal visual acuity, normal visual fields, and PERRLA. Ear: Normal pinna, normal external auditory canal, and the tympanic membrane is clear and not bulging. 

On the whisper test, it was adequate. Nose: On inspection, has a normal shape of the nose, the nasal mucous membranes are moist and moist. On palpation of the sinuses, there was no tenderness elicited. Throat: The oral mucous membrane is moist and pink, the uvula is in the midline, and the posterior pharynx and tonsils are not erythematous and have no exudate.

Neck: On inspection, there are no scars and no swellings. On palpation, the trachea is in the midline, with no swellings, no tenderness, and no lymphadenopathy.

Musculoskeletal: Normal musculoskeletal development and gait, has a good body posture, no bone deformities, no joint swelling, and all her limbs and digits are present. The area over her carpal tunnel on the right wrist with touch but no crepitations. She has a weakened right thumb abduction, and the strength is also weakened at 3/5. The Hoffmann-Tinel sign and Phalen sign are both positive. All the other limb’s muscle power is normal and the tendon reflexes are normal.

Skin: Her skin is per ethnicity with no rashes. On palpation, it is warm, well-perfused, with a normal skin turgor.

Cardiovascular: On examination, no chest deformities, no scars, no hyperpigmentation, and no scars. On palpation, no tenderness, no finger clubbing, no edema, and peripheral pulses were all palpable with normal rate and rhythm and the capillary refill was normal. On auscultation, S1 and S2 were heard with no murmurs or added sounds.

Respiratory: On inspection, the chest moves with respiration, no scars, no deformities, and she does not use accessory muscles. On palpation, no tenderness, chest expansion is symmetrically equal, and no palpable masses. On auscultation, normal breath sounds.

Gastrointestinal: On inspection, abdomen moves with respiration, it is flat, no scars, no hyperpigmentation, and no swellings. On auscultation, bowel sounds were heard in all quadrants. On percussion, tympanic sound with dullness on the spleen and liver. On palpation, the abdomen is soft, warm, with no organomegaly, and no tenderness.

Genitourinary: On inspection, the pubic hair is shaved, with normal external genitalia, and no vaginal discharge. On palpation, the bladder is non-palpable, has no suprapubic tenderness, and the uterus is normal in size with no cervical motion tenderness.

Neurological: She is awake, alert, and is oriented to place, person, and time. She is cooperative during the assessment, has a normal tone, and normal thought process. Her cranial nerves are all grossly intact and she has normal reflexes. She has a normal muscle tone and the sensations to pinprick are normal.

Diagnostic Tests:

There are no specific blood tests that are required for this patient but some tests such as HbA1c can be carried out to rule out diabetes. Also, no imaging studies will be required for this patient but a nerve conduction test can be done.

According to Gupta et al. (2017), HbA1c is a test that is carried out to determine the average blood sugar levels in the last 2-3 months. This test will be carried out to help rule out diabetes from the patient

A nerve conduction test is a test that is used to measure how fast nerve signals are transmitted through the nerve and help to determine the extent and presence of nerve injury (Srikanteswara et al., 2016). This test will be carried out to help determine the extent of the nerve injury in this patient’s right wrist joint.

Differential diagnosis

Carpal tunnel syndrome- Genova et al. (2020) highlighted that carpal tunnel syndrome which is also known as median nerve compression is a group of characteristic signs and symptoms occurring due to compression of the median nerve within the carpal tunnel. It is characterized by paresthesia, pain in the median nerve distribution, and numbness. The patient is the case study presented with pain in the right wrist joint, numbness, and tingling sensations in the thumb, index, and middle finger. On examination, the area over her carpal tunnel on the right wrist was tender, has a weakened right thumb on abduction, and the strength is also weakened at 3/5. The Hoffmann-Tinel sign and Phalen sign are both positive.

Thoracic outlet syndrome- According to Illig et al. (2021), thoracic outlet syndrome is a collective title for a group of disorders that occurs as a result of compression of nerves and blood vessels in the thoracic outlet. It is characterized by pain in the shoulder and neck and numbness of the fingers in the affected side. The patient in the case study however does not have neck or shoulder pain and they also had tingling sensations in their fingers.

Diabetic peripheral neuropathy- Diabetic peripheral neuropathy is the damage to one or more nerves resulting in decreased sensations or movements (Iqbal et al., 2018). It occurs in patients who have diabetes type 1 and type 2. The patient in the case study has a family history of diabetes, she is a known hypertensive on treatment and her age increases her chances of diabetes.

References

• Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal tunnel syndrome: a review of literature. Cureus, 12(3).
• Gupta, S., Jain, U., & Chauhan, N. (2017). Laboratory diagnosis of HbA1c: a review. J Nanomed Res, 5(4), 00120.
• Illig, K. A., Rodriguez-Zoppi, E., Bland, T., Muftah, M., & Jospitre, E. (2021). The incidence of thoracic outlet syndrome. Annals of Vascular Surgery, 70, 263-272. 
• Iqbal, Z., Azmi, S., Yadav, R., Ferdousi, M., Kumar, M., Cuthbertson, D. J., … & Alam, U. (2018).  Diabetic peripheral neuropathy: epidemiology, diagnosis, and pharmacotherapy. Clinical therapeutics, 40(6), 828-849.
• Srikanteswara, P. K., Cheluvaiah, J. D., Agadi, J. B., & Nagaraj, K. (2016). The relationship between nerve conduction study and clinical grading of carpal tunnel syndrome. Journal of clinical and diagnostic research: JCDR, 10(7), OC13.