Right Hand Numbness

Chief Complaint: A 58 year-old female presents with 2 months of right hand numbness and tingling.

Domain A: Data Acquisition

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

Relevant History:

  • Is there pain?
  • Is there specifically neck pain?
  • What are the pain characteristics?
  • Where exactly in the right hand is the numbness and tingling?
  • Onset/duration/radiation/aggravating and alleviating factors?
  • Is there numbness, tingling, or pain anywhere else on the body, such as the other hand or the lower extremities?
  • Is there any bowel/bladder/gait dysfunction?
  • What has she tried so far to alleviate the problem?
  • Family history?
  • Past Medical and Surgical History?
  • Medications?

Relevant Physical Examination:

  • Vital signs
  • Manual muscle testing (i.e. “myotome scan” of the upper limbs more so than lower limbs)
  • Sensory examination
  • Reflex testing
  • Special testing: Spurling, Tinel at wrist and medial epicondyle, Phalen, Reverse Phalen, Carpal Compression Test, Froment, “OK” sign, Hoffman

+ Challenge Question

  • How does one correctly perform the Phalen test?

+ Challenge Answer

  • The examiner asks the patient to extend his/her elbows while fully flexing the wrists, and to hold this position for 30-60 seconds. If the patient’s typical hand paresthesias/pain are reproduced, then the test is positive and suggestive of Carpal Tunnel Syndrome (median neuropathy at the wrist).
 

Domain B: Problem Solving

The patient exhibits normal strength and reflexes. However, there is decreased sensation to light touch in the 3rd and 4th digits of the right hand. The Tinel tests at the right elbow and wrist are positive.

+ What is your differential diagnosis?

  • Carpal tunnel syndrome (median neuropathy at the wrist), ulnar neuropathy at the elbow, cervical radiculopathy, peripheral neuropathy, brachial plexopathy, polyneuropathy, cervical myelopathy, stroke.

The patient tries your suggested treatment program for 4 weeks. She sees you in follow-up, noting that her numbness has worsened and she is having trouble buttoning her shirt each day.

+ What would be your next action in the workup of this problem?

  • Electrodiagnostic studies (EMG/NCS)
  • Consider MRI of cervical spine depending on EMG/NCS results
 

Domain C: Patient Management

EMG/NCS of the right upper extremity reveals median neuropathy at the wrist of moderate severity. She has failed wrist braces and NSAIDs.

+ How would you proceed with treatment?

  • Offer right carpal tunnel injection
  • Discuss potential surgical intervention on the flexor retinaculum via potential hand surgeon referral

+ Challenge Question

  • What are some of the electrodiagnostic findings you would expect to see in moderate or severe carpal tunnel syndrome as opposed to mild disease?

+ Challenge Answer

  • Increased involvement of the median motor fibers, including prolonged motor latency, reduced motor amplitude, and evidence of active denervation on needle exam as indicated by the presence of fibrillations and positive sharp waves.
 

Domain D: Systems-Based Practice

The patient’s insurance company denies the request for a carpal tunnel injection.

+ How would you proceed?

  • Call the insurance company and perform a peer-to-peer discussion, ask them for the reason for denying the request, and explain the conservative treatment already tried and failed. Explain the medical necessity and rationale for the next step (injection).
  • Appeal the decision.
 

Domain E: Interpersonal and Communication Skills

Your peer-to-peer discussion is successful, and the insurance company approves the carpal tunnel injection. The patient agrees to proceed with the carpal tunnel injection. However, 2 days after the injection your office receives a phone call from the patient, who is upset. She states, “I just looked up what you injected into me. You never told me you were going to inject steroids into my body! I know how bad those mess you up! You are just trying to line your pockets so you can buy your next car!”

+ How would you respond?

  • A good example response would be: “Firstly, I want to say that I am so sorry that you are going through this in the first place. This is a difficult problem for you to suffer with, and I also know that it’s not easy to sort through the treatment options. I sincerely apologize for any miscommunications or misunderstandings that may have taken place. I want to assure you that you and I are on the same team. If you have time, I would be more than happy to discuss the treatment we have tried so far, and the most reasonable next steps we could take to help alleviate your hand numbness, as well as why these steps are necessary, and what might happen if we don’t attempt to treat this problem appropriately. Additionally, you are correct, a carpal tunnel injection would involve corticosteroids; again, I apologize for not discussing that aspect in more detail with you at your visit, but I would be happy to discuss the reasoning for corticosteroid usage in your case, as well as any potential side effects we may see from this procedure. You can always reach out to me in the future with any questions or concerns. Additionally, I will send a copy of my note to your primary care physician so that we are all on the same page. Is there anything else you would like to talk about today, or any other questions you might have?”
  • Naturally your answer will vary greatly, but something along these lines will suffice. Always “ally yourself” with the patient, and present the situation as “you and the patient vs. the problem”, instead of “you vs. the patient”. Never “go head to head” with the patient, as the examiners will see you as combative, rather than collaborative. Always ask if there are any further questions the patient has, and always keep the patient’s primary care physician in the loop.