Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is a 65-year-old female called Mary Poppin, presenting with restricted hand movements. Please take a history and perform an appropriate examination.
Patient History:
Mary Poppin, a 65-year-old female, retired.
Over the last few years, you have been developing increasing difficulty using your right hand. You are unable to straighten your right ring and little fingers fully at all. You tried to flick your finger back but it didn't help. Because of this, you have been dropping things easily on the floor as you couldn't let go of things properly - how embarrassing! You now have difficulties using your right hand, for example, washing your face or fitting your hand into a glove to do gardening. Because you are mostly right-handed - you are becoming more frustrated day by day! You haven't noticed any pain in your hands as of yet. No stiffness. No previous hand trauma/injury.
Idea, Concern, Expectation:
You think this might be arthritis, as your mother got it. You are concerned as you are struggling with activities at home. You often have to ask your husband to help. You want to become more independent and not rely on others. You would like to free up your hand to do more things on your own.
Past Medical History:
T1DM, epilepsy, hyperlipidaemia
No previous surgeries.
Drug History:
Insulin injections, carbamazepine, atorvastatin
NKDA
Family History:
Arthritis - mother
Social History:
Retired. Used to work in sewing for clothes for most of your life.
You don't smoke, but you used to smoke around ten cigarettes for over 20 years.
You drink a glass of gin and tonic a few times a week.
You live with your husband in a small bungalow.
Examination Findings:
Skin thickening/ puckering/ pitting tethering/ dimpling in the palm of the right hand. Restricted extension of 4th and 5th digits of the right hand and appear in a flexed position at rest. 4th and 5th digits of right MCP joints are limited to 30°, and PIP joints are limited to 10° in the axis.
Firm, longitudinal thickening cords can be palpated from the palm into the affected fingers.
Firm nodules can be felt in the palm of the right hand - fixed to the skin and deep fascia at the distal palmar crease.
Hueston's table-top test is positive - the patient is unable to lay their right hand completely flat on the table.
Neurovascular intact upper limbs
Differentials:
Dupuytren's contracture
Callus
Ganglion
Trigger finger
Epithelioid sarcoma
Ulnar nerve palsy
Investigations:
Clinical diagnosis
Consider monitoring risk factors such as hba1c/glucose for diabetes
Consider ultrasound of the hand
Management: