A 57-year-old woman comes to the office due to discomfort in her right hand. She reports that periodically her fingers "feel numb, with some tingling, sort of like they fell asleep." When the patient shakes her hands, normal sensation is partially restored. The symptoms are more often present at night but are occasionally experienced during the daytime as well. She has not had abnormalities of sensation on the dorsal surfaces of her hands, and she reports no shoulder or neck pain. There is no history of injury to the upper extremities. Medical history is notable for irritable bowel syndrome, mitral valve prolapse, degenerative knee arthritis, and hypertension controlled with lisinopril. She also takes an over-the-counter fiber supplement. The patient works as a bookkeeper. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 32 kg/m². Neurologic examination shows no sensory loss, muscle weakness, or muscle atrophy in the right upper extremity.
Which of the following is most likely in this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0a9_172f_8f63_3b0063cbdde3_MD0005_00 This patient has subjective numbness and paresthesias in the hands with dorsal sparing consistent with carpal tunnel syndrome (CTS). CTS is caused by compression of the median nerve as it passes under the transverse carpal ligament in the wrist. Symptoms of CTS are frequently worse at night and may be relieved by shaking the hands ("flick sign") or running them under warm water. transverse carpal ligament CTS is primarily a clinical diagnosis, and several physical examination maneuvers can be used for confirmation. The Phalen test consists of hyperflexion of the wrist, either by pressure from the examiner with the patient's elbow extended or by having the patient press the dorsal surface of the hands together. Hyperflexion at the wrist exacerbates compression of the median nerve in the carpal tunnel, and a positive test reproduces characteristic symptoms within one minute. Other useful maneuvers that can reproduce or worsen the patient's symptoms include: Tinel sign (tapping over the nerve in the carpal tunnel) Hand elevation test (holding the hand over the head) (Choice D) Reverse Phalen test (hyperextension of the wrist) Sensory deficits and atrophy of the thenar muscles may be seen in advanced cases, but these signs are less sensitive. (Choice A) The painful arc test refers to the onset of shoulder pain when the arm is abducted between 60 and 120 degrees. This finding is characteristic of rotator cuff impingement, which typically presents with shoulder rather than hand pain. (Choice C) A lower cervical radiculopathy (eg, C6 or C7) can cause pain and paresthesias that are worse with neck movement, but otherwise may resemble CTS. However, a cervical radiculopathy can also involve the dorsum of the hand and may be associated with diminished upper-extremity reflexes or proximal arm weakness. Also, a cervical radiculopathy often causes pain in the neck and upper arm, whereas CTS rarely causes referred pain proximal to the distal forearm. (Choice E) DeQuervain tenosynovitis is due to overuse of the extensor pollicis brevis and abductor pollicis longus tendons, and presents with sharp pain at the base of the thumb. Pain is reproduced by ulnar deviation at the wrist, especially when the thumb is held in opposition across the palm (Finkelstein test). Educational objective: Carpal tunnel syndrome presents as pain or paresthesias in the median nerve distribution. Reproduction of symptoms by hyperflexion of the wrists (Phalen test), tapping over the median nerve (Tinel sign), and hand elevation above the head can help to confirm the diagnosis.

A 57-Year-Old Woman Comes to the Office Due to Discomfort