Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year Doctor working in the Emergency Department. Your next patient is a 44-year-old woman called Cardi Cee, who presents with hand numbness. Please take a history and perform an appropriate examination.
Patient History:
Your name is Cardi Cee (44-year-old woman) – office worker.
Over the last few months, you noticed worsening numbness in your right hand – mainly affecting your right hand's thumb, index, and middle fingers. Sometimes around these sites, you will notice some pins and needles/ a burning sensation / aching pain, which tend to come up intermittently and worsen at night-time and can wake you up from sleep. You tried multiple methods of relieving symptoms, such as hanging your hand out of bed at odd angles or shaking your hand multiple times – which helped slightly. You occasionally have stiffness in the fingers of both hands, especially in the morning, lasting around 30-45 minutes, improving throughout the day.
You also noticed you have been becoming clumsier as usual in the last few months. You feel weak in doing things with your right hand i.e. opening a jar or turning a wrench. Sometimes items just slip out from your right hand! Because of this, you dropped and broke a few cups in the kitchen, how embarrassing!
Ideas, Concerns, Expectations:
You think you might have arthritis but are not too sure. You are concerned because you are becoming less able to cope at home due to clumsiness. You would like to see if you can be seen by a rheumatologist about this.
Past Medical History:
Obesity, Hypothyroidism, Type 2 Diabetes, previous fracture at the right wrist when you were a child - this was managed conservatively.
Drug History:
Atorvastatin, levothyroxine, metformin
NKDA
Family History:
Dad also has similar symptoms in the past – all you know is that he has acromegaly. Mother has arthritis, but you do not know which one.
Social History:
You work as an office worker (if asked specifically, your job involves heavily typing on a keyboard for various clients).
Smoke five cigarettes daily for five years.
Don't drink alcohol.
Examination Findings:
Overgrowth features of acromegaly might include large nose/tongue/hands/feet/ protruding jaw/ prominent forehead + brow
Wasting/loss of sensation around the thenar muscles (right)
Weaknesses in flexion of the index and middle fingers of the right hand. Weakness on right thumb abduction/opposition/ flexion. Weakness in grip strength(right hand).
Difficulty with fine movement involving thumb (right)
Reduced sensory innervation of the median nerve distribution of the right palm and full fingertips of the right hand's thumb, index and middle finger.
Positive for Phalen’s test, Tinel’s test and carpal tunnel compression test of the right hand.
Differentials:
Carpal Tunnel Syndrome / Median Nerve Palsy
Rheumatoid / Osteoarthritis
Underlying undiagnosed acromegaly
Tendonitis/ fibrositis
Investigations:
Bedside:
Observations
Perform a Carpal Tunnel Questionnaire
Imaging:
Consider XR of the hands for arthritis
Ultrasonography Wrist + Hand (space-occupying lesion may be identified)
MRI scan (space-occupying lesion may be identified)
Special Test:
Nerve conduction studies e.g. electroneurography/ electromyography (focal slowing of conduction velocity in median sensory nerves + prolongation of median distal motor latency)
Management (Carpal Tunnel Syndrome):