Ms. Henson submitted a sick call slip complaining that her right hand pain, ongoing for approximately five months, had worsened. She was previously seen in Nurse Sick Call multiple times and was provided Ibuprofen per the nursing protocols in use at the facility. Today you are the Nurse Sick Call nurse, and escort Ms. Henson into the exam room so you can conduct the evaluation. You decide to use both the pain protocol and the musculoskeletal protocol.
Nursing Sick Call Evaluation
Ms. Henson stated that the pain was initially more like a tingling sensation when she first woke up in the morning that stayed right at the base of her right thumb and index finger. Over time, the symptoms worsened to include happening at night, and pain that woke her up multiple times a night. Although she tried to sleep with her wrists extended to minimize the pain, she would twist and turn during sleep and the symptoms returned. Now it has worsened to the point where she feels a burning pain in her right hand that affects her thumb, middle and index finger. Sometimes the symptoms radiate to the wrist and her lower right forearm. She also complains of decreased strength in her right hand, which is now impeding her ability to work in the laundry. The last time she was seen in Nurse Sick call for the tingling was two weeks ago. She was given ibuprofen 200 mg 2 tablets twice a day for 10 days. The ibuprofen did not alleviate all symptoms, but it felt better when she was taking it and now is presenting with a request for more. Ms. Henson’s health history includes Hypertension and Type II Diabetes Mellitus. She is adherent to her medication regimen of lisinopril 10 mg per day and metformin 500 mg twice per day.
Allergies: No known drug allergies; no known food allergies.
- Metformin 500 mg PO BID..
- Lisinopril 10 mg PO QD.
Vitals: T 98.6°F, P 88, R 14, BP 138/82, WT 188 lbs, HT 5’7″, BMI 29, blood glucose 134.
General: Alert, oriented x4, well-nourished, cooperative female.
Lungs: clear to auscultation without adventitious sounds
Heart: S1 S2, RRR without murmur, rubs and gallops
Abdomen soft, non-tender to palpation, obese, + bowel sounds all 4 quadrants
Radial pulses intact and strong bilaterally; capillary refill < 3 seconds right and left hands
Range of motion intact to hands and fingers bilaterally, with no discoloration. + pain with movement right hand
CORRECTIONAL NURSE ACTIONS
Because the patient had been seen more than twice for the same complaint, and because of her described symptoms, Ms. Henson was seen by the Provider immediately, as he was there for Provider Sick Call.
Ms. Henson is then seen by the Provider.
Review of Systems
The patient’s ROS is positive for numbness/tingling in the median distribution of the right hand, weakness including dropping objects, or difficultly grasping cups or utensils for long periods. The ROS is negative for fatigue, weight loss, night sweats, injury, or trauma to the right arm/hand. She denies neck pain or radiation of pain that originates from the cervical spine. She also denies joint pain in the elbow or shoulder of both upper extremities.
Provider Physical Examination
Vitals: as above, as the patient was evaluated in Provider Sick Call immediately.
General: Well-nourished, pleasant female. Right hand dominant.
Psychiatric: Alert, oriented x 4, Cooperative on exam.
Skin, Hair, and Nails: Warm, dry, no apparent rashes. No abnormal findings with hair or nails.
Peripheral Vascular: Radial pulses intact; capillary refill brisk, < 3 seconds with no discoloration of the hand or fingers bilaterally.
Musculoskeletal: Positive Tinel sign in right wrist, negative in left; positive Phalen maneuver after 30 seconds of holding posture; full range of motion in fingers, wrists, elbows, and shoulders bilaterally.
Neck: Supple without tenderness to palpation or enlargement of thyroid; full range of motion with no symptoms with flexion/extension/rotation of the cervical spine.
Grip strength reduced 4/5 in the right hand and reduced compared to non-dominant left hand. Atrophy of the thenar eminence in the right hand in comparison to the left hand noted. Neurologic: Diminished light touch sensation in the right hand in the median nerve distribution; upper and lower extremity reflexes equal and symmetrical bilaterally (2+).
Differential Diagnoses for Ms. Henson
Vitamin B12 deficiency might be considered because the patient is on metformin. Since 2017, the American Diabetes Association has included a recommendation for periodic B12 measurements, especially in diabetics with anemia or peripheral neuropathy.
Diabetic neuropathy should be suspected in a patient with diabetes; however, symptoms would likely present in the feet prior to the hands as well as be bilateral in nature versus affecting only the dominant hand.
Carpal tunnel syndrome (CTS) should be high on the list. The patient works in the laundry folding clothes (repetitive movements) and has pain and diminished sensation. The nighttime pain is also a classic symptom of CTS. Positive Phalen and Tinel signs are suggestive of CTS. Thenar atrophy is a late sign of both CTS and diabetic neuropathy.
Arthritis of the wrist or carpometacarpal joint of the thumb would be indicated by painful motion of the thumb or wrist joints and radiographs indicating arthritic changes within the joint space. It is possible for a patient to have both arthritis and CTS.
Cervical radiculopathy is unlikely because the patient would be expected to report pain in the cervical spine along with symptoms in the upper arm as well as the wrist and hand; symptoms may be provoked with changes in neck position. This does not fit the patient’s presentation.
Pronator syndrome, where the median nerve is compressed at the elbow, would be indicated by tenderness to palpation at the proximal forearm (over the pronator teres muscle) and is not typically associated with pain or discomfort at night.
Most Likely Diagnosis: Carpal Tunnel Syndrome (CTS)
The patient’s signs and symptoms are consistent with median nerve compression at the wrist including diminished sensation, two-point discrimination, strength, and muscle bulk in the median-nerve-innervated areas of the hand. Her nighttime pain also points to CTS. Additionally, there is a higher prevalence of CTS among persons with Diabetes Mellitus, females, older age and those overweight.
X-rays of the wrist are obtained in suspected cases of CTS if there is limitation of range of motion in the wrist.
Nerve conduction studies were ordered. The patient went out the following week to a community provider.
Electromyogram (EMG) was considered but not done because it is more invasive. EMGs are unlikely to be necessary for the diagnosis of CTS unless there is true muscle wasting and weakness present and the diagnosis is still unclear after Nerve Conduction Studies.
X-rays were performed onsite by the mobile company the next day, which showed no significant bony pathology.
Nerve Conduction Studies were positive for Carpal Tunnel Syndrome.
Carpal Tunnel Syndrome is a neuropathy caused by compression and/or excess traction of the median nerve where it passes through the carpal tunnel. The carpal tunnel is a space surrounded by the flexor retinaculum and the carpal bones. The superior aspect of this space is the transverse carpal ligament. The space houses nine flexor tendons, their sheaths, and the median nerve. Most cases of Carpal Tunnel Syndrome are idiopathic, but some are associated with anatomic changes like hypertrophy of the fibrous flexor sheaths, which may be associated with repetitive movements of the wrist.
The most common symptoms of Carpal Tunnel Syndrome are numbness, pain, and/or paresthesia in the thumb, index, middle, and radial half of the ring finger. Symptoms often awaken the patient from sleep, and are commonly seen during pregnancy and in patients with Diabetes Mellitus and rheumatoid arthritis.
Overall, surgical intervention for Carpal Tunnel Syndrome significantly improves the outcomes when based on the Symptom Severity Scale and Function Status Scale.
Order a wrist splint without metal to keep the wrist in a neutral position or at a slight extension to alleviate pressure on the median nerve. This should be used day and night.
Use ice as needed for symptom relief – request it at medpass.
NSAID for inflammation – monitor blood pressure as an elevation with NSAID use may occur.
Follow-up in 4 weeks, or sooner if symptoms worsen.
Consider referring to hand specialist due to physical exam finding—atrophy of the thenar eminence in the right hand.
If no improvement, consider corticosteroid injection for symptom reduction, and referral to hand specialist for evaluation and rehabilitation.
PATIENT EDUCATION TOPICS
Any medication ordered and potential side effects
The identification and avoidance of exacerbating activities and hand/wrist positions.
The importance of splinting the affected hand in a neutral position 24 hours per day (or at least through the night) as activity permits.
Proper application of the splint.
The treatment plan developed for the patient, including consideration of corticosteroid injections, physical therapy, and surgical interventions if the condition doesn’t improve with splinting and conservative treatment.
Red flags, including loss of sensation, inability to pick-up/hold objects, and worsening of the pain and numbness, for which health staff must be notified immediately.
At the follow-up visit, Ms. Henson returned for evaluation, but no improvement was shown using wrist splint and NSAIDs, so she was referred to an outpatient orthopedic clinic for completion of the Nerve Conduction Studies.
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*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.