A 34-year-old woman comes to the emergency department due to sudden onset of tingling and numbness in her left hand. She is an assistant chef at a nearby restaurant and was lifting a box earlier in the day when she heard a "pop" and her left hand went numb. The patient's numbness is in a glove distribution: Her fingers, entire left hand, and wrist are numb, with normal sensation above her wrist. The patient describes her numbness as feeling like "pins and needles." Medical history is insignificant. The patient allows the nurse to take her vital signs but refuses any further physical examination, insisting that it will worsen her discomfort. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 16/min. The patient asks for a doctor's note to excuse her from work, fearing that her condition will worsen if she does not take some time off to heal. Which of the following is the most likely diagnosis?

Question

A 34-year-old woman comes to the emergency department due to sudden onset of tingling and numbness in her left hand.  She is an assistant chef at a nearby restaurant and was lifting a box earlier in the day when she heard a "pop" and her left hand went numb.  The patient's numbness is in a glove distribution:  Her fingers, entire left hand, and wrist are numb, with normal sensation above her wrist.  The patient describes her numbness as feeling like "pins and needles."  Medical history is insignificant.  The patient allows the nurse to take her vital signs but refuses any further physical examination, insisting that it will worsen her discomfort.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 72/min, and respirations are 16/min.  The patient asks for a doctor's note to excuse her from work, fearing that her condition will worsen if she does not take some time off to heal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Malingering is characterized by feigned or grossly exaggerated physical or psychological symptoms with the intention of obtaining secondary gain (eg, financial compensation, leave from work, narcotics). There is usually a marked disparity between the patient's disability and the objective findings. The distribution of this patient's sensory symptoms (fingers, entire hand, and wrist only) is inconsistent with known nerve pathways. In addition to the irregularity of her reported symptoms (including their occurrence after a "pop"), she refuses a complete examination. These inconsistencies combined with her request for a doctor's note excusing her from work (ie, secondary gain) should raise the suspicion of malingering. (Choice A) Conversion disorder is typically preceded by an emotional trigger and is characterized by unexplained neurological symptoms that are incompatible with recognized neurological conditions. In contrast to malingering, there is no external incentive and the symptoms are not intentionally produced. (Choice B) Factitious disorder is characterized by the intentional production of false physical or psychological signs or symptoms to assume the sick role. Unlike patients with malingering, those with factitious disorder receive no secondary gain. (Choices D and F) Mononeuropathy and radiculoneuropathy produce symptoms in a dermatomal distribution and are therefore incapable of producing the glove distribution pattern reported by this patient. (Choice E) Although a length-dependent distal polyneuropathy may produce stocking-glove distribution sensory loss, the syndrome typically has an insidious onset, is associated with comorbid illness (eg, diabetes mellitus, vitamin deficiency, alcoholism), affects the feet first, and is most often bilateral. Educational objective: Malingering is the intentional production or exaggeration of physical or psychological symptoms for secondary gain. Malingering should be suspected when a patient is reluctant to be examined or treated and there is a discrepancy between symptoms and objective findings. References: Factitious disorders and malingering: challenges for clinical assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/24612861) Estimated costs of malingered disability. (http://www.ncbi.nlm.nih.gov/pubmed/23800432)

A 34-Year-Old Woman Comes to the Emergency Department Due to Sudden