Left Hand Pain

Chief Complaint: A 27 year-old female presents with left hand pain.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

  • How did this begin? Onset and context of symptoms? Was there any injury recently or in her past?
  • Regarding pain, what is the location, duration, intensity, quality, radiation, constant/intermittent, aggravating/alleviating factors?
  • Is the pain unilateral or bilateral?
  • Are there associated changes in terms of weakness, numbness, tingling, bowel/bladder dysfunction, skin changes?
  • Has the patient had any workup or treatment so far for this pain?
  • Functional history and current functional status, including equipment usage?
  • Social history and work status?
  • Family history?
  • Past Medical and Surgical History?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Inspection
  • Palpation
  • Manual muscle testing, sensation, reflex examination of bilateral upper limbs
  • Special testing as directed by the history
 

DOMAIN B: PROBLEM SOLVING

The patient is a 27 year-old female who presents with 2 years of left wrist and hand pain. She was exercising and accidentally dropped a 35lb dumbbell onto her left wrist, resulting in a left scaphoid fracture for which she underwent surgical fixation. Her presurgical left wrist pain improved following that operation, but over the next several months she developed gradual onset vague left wrist and hand burning pain, swelling, abnormal sweating in the left hand, and extreme sensitivity to light touch over the left hand. She states the left hand feels “funny” in addition to painful. She denies other concerning symptoms elsewhere. She has tried oral acetaminophen and ibuprofen with no relief. She stopped working as a chef due to the pain. On examination, she has allodynia over the left wrist and hand dorsally, and you meet significant tissue resistance when attempting to passively extend her left fingers.

+ What tools would you use to assist you in generating your differential diagnosis?

  • Clinical knowledge from residency and experience in independent practice
  • Discussion with colleagues (via de-identified case information)
  • Researching the primary literature
  • Subscription-based peer-reviewed services (uptodate, dynamed, etc.)

+ What is your differential diagnosis?

  • CRPS 1 or 2 (complex regional pain syndrome type 1 or type 2), central sensitization, failed surgical fixation, surgical nonunion, extensor tendinopathy, undiagnosed wrist/hand fracture, carpal tunnel syndrome, ulnar neuropathy, radial neuropathy, cervical radiculopathy, ganglion cyst, thalamic stroke, malingering.

+ What are your next steps in the workup for this problem?

  • X-rays of left wrist and hand
  • EMG left upper extremity
  • Triple phase bone scan
  • Consider diagnostic ultrasound or MRI of left wrist/hand

+ Your next steps result in the following:

  • X-rays of left wrist and hand: patchy demineralization of the carpal bones
  • EMG left upper extremity: normal
  • Triple phase bone scan: increased uptake in the left wrist during phase three
 

DOMAIN C: PATIENT MANAGEMENT

+ How would you manage this patient?

  • First I would educate the patient about the diagnosis of CRPS, prognosis, and management options going forward.
  • This patient has failed oral acetaminophen and NSAIDs. If no contraindications, I would start anti-neuropathic pain medication such as gabapentin, pregabalin, amitriptyline, nortriptyline, or duloxetine. I would recommend a topical medication such as lidocaine, capsaicin cream, or even a compound cream to help improve the skin sensitivity/allodynia. If no improvement, a course of oral corticosteroids could be considered. I would recommend TENS therapy in addition to occupational therapy to promote use of the affected hand and restore range of motion. Ultimately a work hardening program could be considered.
 

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient follows your recommendations and does not improve. Her pain is worsening.

+ How would you proceed?

  • I would recommend either a peripheral nerve block over the region of her pain, vs. a stellate ganglion block, depending on how comfortable she is with either option after I explain the risks/benefits, and rationale of both.
 

+ The patient adamantly refuses stellate ganglion block. The peripheral nerve block is denied by insurance. How would you proceed?

  • Options include:
    • Call insurance company and perform peer-to-peer discussion.
    • Appeal the decision.
    • Discuss with the insurance company what services they would cover in her case.
 

The insurance company approves the stellate ganglion block. The patient ultimately agrees to undergo this procedure and receives complete pain relief for 1 week, before her symptoms gradually return.

+ What would you recommend next?

  • Conservative and interventional measures have failed. Repeat stellate ganglion block could be considered, but this patient should also be considered for neuromodulation, such as peripheral nerve or spinal cord stimulation.

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

This is the role-playing portion of the encounter. Pretend that I’m the patient.

Patient: “Doctor, I’m sick of being shuttled around. I am so hopeless. Nothing works. I can’t even hold a job due to the pain. I need you to recommend that I am permanently disabled and cannot work.”

+ What is your response?

  • I am so sorry that you are going through this. CRPS is incredibly difficult to experience. It can severely limit your quality of life and your ability to function. I know we have been trying very hard to improve your pain and your function, and I am disappointed that nothing has helped you significantly or for a long enough time. However, you are not out of options. I want you to consider neuromodulation as we discussed previously. I think you should strongly consider it, as there is evidence that it is beneficial for CRPS-related pain. I understand and agree that you cannot work right now due to your constant, severe pain. I am happy to write a recommendation that you cannot work in your current state. However, I do not yet believe that we have reached your permanent maximal medical improvement; there is reasonable hope that your pain and function can improve enough for you to be able to work.

+ The patient responds:

  • “Are you kidding me? You think I can wait around another 6 months to get in with someone who will then make we wait another 6 months to get a stimulator implanted that may or may not even work? I can’t work! I need my permanent disability payout!”

+ Your response?

  • Please understand that I want your pain improved as fast as possible and effectively as possible. I am so sorry that you are having to deal with your current situation. I certainly don’t know how it feels, but I know it is incredibly difficult. I know we can work together as a team to improve your pain and function. Please allow me to work hard to find the fastest and most effective solution for your pain.

+ The patient responds:

  • I don’t want a stimulator or your useless excuses! All I’m hearing from you is that you can’t help me. I can’t believe I even came here. You are trash. You’re lucky you didn’t have to call security on me today.

+ Your response?

  • Again, I am so sorry for your ongoing pain, and that our efforts have not been successful in treating your pain or improving your function. I have been willing to work hard to find the best solution for you. Unfortunately I no longer feel that our patient-doctor relationship is one of trust and harmony. I am willing to provide emergency care for you as needed, but unfortunately I do believe it is in both of our best interests to transfer your care to one of my partners or another physician who is capable of treating this problem for you. Please allow me to show you to the exit.
  • Note: This case illustrates the unfortunate reality that despite your best, most honest, and most genuine efforts, some patients just will not like you. If you ever encounter a situation in which you no longer feel safe (above), or that the patient-doctor relationship of teamwork has become fractured, then it is in both your and the patient’s best interest to terminate the relationship and transfer care to another capable physician. In these cases, always inform the patient that you are available to provide urgent/emergent care until they become established with a new physician.