Main Question Post: Week 9 Discussion – Case Study # 2 Patient Initials: T. M. Age: 47 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): Complaint of pain to the right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. History of Present Illness (HPI): T. M is a 47-year-old obese African American female who present at the clinic with a complaint of pain to the right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. The patient voiced an upsurge in pain whilst at work.
The patient is a hairstylist and she indicated that the pain interferes with her utilizing her hair equipment’s which spearheads to her dropping them. The patient indicated that her pain scale is 10/10 while working and 8/10 when resting. The patient disclaims any past or present injury to the right wrist or fingers. The patient has not taken any medication to help treat or relieve her right wrist pain and has not consulted any healthcare provider for her pain. Likewise, flexion & extension of her wrist was a slight painful. Medications: Multivitamin
Allergies: No Known Allergy Past Medical History (PMH): Disclaims any medical history. Past Surgical History (PSH): Disclaims any surgical history. Sexual/Reproductive History: Married and sexually active in a heterosexual relationship with one partner, no methods of contraception. She has four children with two older ones living away from home while two younger ones remain at home with their parent. Patient disclaims any history of sexually transmitted diseases. Personal/Social History: Disclaims smoking, drinking alcohol, or using any illegal drugs.
Executes ADLS independently, and engaged in healthy eating with plentifully of fruits and vegetables. Immunization History: Patient up to date on her immunization. Last flu vaccination December 2016. Indicated that pneumonia vaccine not received. Significant Family History: Father: Diabetes and hypertension Mother: Seasonal allergies Brother: Asthma Grandparents: unable to provide any information Lifestyle: A 47-year-old female hairstylist working 10 to 12 hours at a salon for JC Penny, 5 days a week. Married now for 25 years, with two daughters and two sons.
The patient is typically healthy and very energetic in the church and serves as a lead usher in the church. Patient has a remarkable family assistance. Review of Systems: General: Patient alert and oriented x 4 (person, place, time and event) and well-garbed. Disclaims any fever, weight changes, chills or night sweat episodes. • HEENT: Disclaims headaches or dizziness and able to support head with no difficulty, disclaims any changes in vision, hearing, & equal bilateral smile. No missing teeth noted. Indicated that last dental visit was 3 months ago.
Refutes any sinus or throat distress, and congestion. • Neck: Disclaims neck stiffness, throat pain or problems swallowing. • Breasts: Disclaims any breast pain, soreness, lumps or discharge. • Respiratory: Disclaims smoking or any problem with SOB, difficulty breathing or hemoptysis. • Cardiovascular/Peripheral Vascular: Disclaims chest pain or discomfort, palpitations and denies any history of heart disease. • Gastrointestinal: Refutes nausea or vomiting, diarrhea or constipation or hematemesis and disclaims history of anorexia. • Genitourinary: Disclaims dysuria, hematuria or urgencies.
Sexually active with the use of condoms as a method of contraceptive. · Musculoskeletal: Patient narrates pain and problem moving right wrist with flexing and extending wrist at work. Patient states she has spasmodic pain using right wrist at work. The pain delineated as a piercing pain that sprouts down her right thumb and index finger triggering numbness and tingling. Refutes any fractures, trauma or arthritis. · Psychiatric: Refutes any depression, anxiety or suicidal thoughts. • Neurological: Refutes any headaches, seizure activities, or dizziness.
The patient indicated numbness and tingling in the right thumb and index fingers causing the incapability to use her hairstyling equipment. • Skin: Refutes any skin rash, lesions, and wounds. •Hematologic: Refutes history of anemia, any abnormal bleeding or easy bruising. • Endocrine: Refutes any unexplained weight loss, polyphagia, polydipsia, and polyuria. • Allergic/Immunologic: Refutes any allergic or immunologic deficiencies, pruritus, and swelling. OBJECTIVE DATA: Physical Exam: General: A 42-year-old obese African American female in good health with virtuous posture and steady gait.
Patient well groomed, with no foul odor noted, alert and oriented x 4 and answers appropriately to every questions and discussion and splinting of right wrist and grimacing noted. • Vital signs: BP: 165/89, HR: 99, R: 20, T: 98. 9, Ht: 5’3, Wt: 285 & 02 sats 99% • HEENT: o Head: Normocephalic with no visible or palpable masses, depressions, or scaring. o Eyes: Visual acuity intact, conjunctiva clear, and sclera non-icteric intact. Pupils equal, round and reactive to light with accommodation. Fundi with normal optic disc and vessel. No exudate or hemorrhage noted. Ears: canals clear bilaterally, left and right tympanic membrane pearly grey with light reflex and visible bony landmarks. Oropharynx clear with no exudates and hearing intact. Nose: No external lesions, mucosa non-inflamed, septum, and turbinates normal o Mouth: Mucous membranes moist, no mucosal lesions.
No obvious caries or periodontal disease. No gingival inflammation noted. o Pharynx: Mucosa non-inflamed with no tonsillar hypertrophy or exudate • Neck: No deviation, nodules, or bruits noted • Chest: Thorax symmetrical. Negative for masses and no tenderness during palpations. Lungs: Respirations even and unlabored. Breath sounds clear to all lung lobes. • Heart: No cardiomegaly. S1/S2 sounds noted with no S3 or S4 noted. • Peripheral Vascular: Pedal pulses 2+ with no peripheral edema noted. • Abdomen: Abdomen flat with symmetric rise and fall. No pulsation noted. No lesions or abdominal scars noted. Bowel sounds noted to all four quadrants. Abdomen soft and nontender to touch. No masses noted. No hepatosplenomegaly. RUQ dullness noted with tympanic sound noted in RLQ, LUQ, and LLQ. • Genital/Rectal: External genitalia intact.
Normal sphincter tone. No masses noted. • Musculoskeletal: Cervical spine without pain on palpation. Bilateral shoulders, elbows, and forearms without pain on palpation. Atrophy noted to thenar muscle to the right thumb. Muscle strength 3/5 to RUE and 5/5 to LUE, LLE, and RLE. ROM to right wrist full but painful. • Neurological: Alert and oriented x 4. Cooperative with appropriate mood and affect. CN 2-12 intact. Sensation diminished to right thumb and index finger. Tinel’s, Phalen’s, and Hand elevation positive to RUE. Right thumb abduction 3/5.
Strength 3/5 to RUE and 5/5 to LUE, LLE, and RLE. Romberg normal, gait normal. Deep tendon reflexes 2+ throughout. • Skin: Skin intact and warm to touch. ASSESSMENT: Labs: • CBC: WBC 8. 4 • CMP: Glucose 135 • Hgb A1C: 4. 5% • C-Reactive Protein: 2. 5 mg/L Diagnostic Test: • EMG: limited by poor needle electrode tolerance. • MRI C-Spine: negative for pinch nerves • X-Ray: negative for fracture and arthritis Differential Diagnosis: • Carpal Tunnel Syndrome • Diabetic Neuropathy • Cervical Radiculopathy • Medial Epicondylitis • Hematoma of Volar Wrist
According to Ibrahim, Khan, Goddard, and Smitham (2012), carpal tunnel syndrome (CTS) lingers as bewildering and incapacitating syndrome existing in about 3. 8 percent of the populace. CTS is an utmost main type of the median nerve condition and relates to approximately 90 percent of neuropathies conditions (Ibrahin et al. , 2012). According to Burton, Chesterton, and Davenport (2014); Ball, Dains, Flynn, Solomon, and Stewart (2015), CTS is a median nerve neuropathy compression at the wrist branded by numbness, tingling dispersal at median nerve towards the thumb, middle finger, index, and radial ring finger, and hand pain.
Approximately 55 to 65 percent of CTS situation correlated with ailments of diabetes, rheumatoid arthritis, and hypothyroidism (Burton et al. , 2014). The patient is mainly probably hurting from carpal tunnel syndrome. The patient toils as a hairstylist and the continual compression of the median nerve with her hair equipment’s have led to her embryonic carpal tunnel syndrome. Torpy, Lynm, and Golub (2011), CTS influence not lone the median nerve many tendons impacted, implementing recurrent tasks like typing, computer labor, or mechanical bustle positions people at the peril of embryonic carpal tunnel syndrome.
According to Torpy et al. , (2011), CTS could trigger or deteriorate from hands overexert, weight gain, and pregnancy. The patient’s neurological analysis outcomes of her Tinel, Phalen, and hand elevation indicated positive to RUE. These analyses are used to assistance the diagnosis of carpal tunnel syndrome. While the patient is obese and at peril for diabetes, diabetic neuropathy could be ruled out since the patient is negative for diabetes per the Hgb A1C.
Likewise, cervical radiculopathy could be ruled out since the patient is not undergoing any neck pain or stiffness and the MRI was negative for any pinched nerve to the C-spine. Medial Epicondylitis can be ruled out since the patient is not undergoing pain in the elbow. This condition witnessed in golfers, which the patient do not perform or play. Hematoma of the volar wrist could likewise be ruled out since the x-ray was negative for fractures. There is no discoloration noted during analysis to the wrist area or swelling. This condition most frequently happens once there has been a wrist injury or fracture.
It is essential that the advanced nurse practitioner is adept in understanding with the ability to appropriately diagnose, treat, and aid the patient in living a comfortable life without distress, which piloting noteworthy healthcare advantage, related to social and economic position (Alfonso, Jann, Massa, & Torreggiani, 2010). Physical therapy and splint usage, cold and hot compression interchange could be suggested, and non-steroid anti-inflammatory can be a script with adequate education to avert deterioration of the nerve damage.
