Case 57: Wilma Burns

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history, conduct a focused examination, outline the most likely diagnosis and negotiate a management plan with Wilma.

The following information is on her summary sheet:

• Past medical history

• Two children, normal pregnancies and delivery

• Vaginal hysterectomy for prolapse aged 45

• Mammogram normal this year

• Medication

• Nil

• Allergies

• Nil

• Immunisations

• Nil known

• Social history

• Non-smoker.

INSTRUCTIONS FOR THE PATIENT, WILMA BURNS

You are a 54-year-old housewife and a keen gardener. For the last few weeks you have noticed pins and needles in your right hand on waking in the morning. This affects the pulps of the thumb, index, middle and half of the ring finger. Sometimes you get this after you have been gardening and in the last week the tingling sensation has woken you up at night. When you shake your right hand you can make some of the tingling go away and by doing this you can get back to sleep.

If the doctor asks, please say that you do not drink alcohol. You last had immunisations when you were at school.

Clinical examination findings

You have carpal tunnel syndrome. Please demonstrate an area of paraesthesia in the distribution of the right median nerve. Sensation is normal but power of thumb abduction is reduced. Tinel’s sign* and Phalen’s sign† are positive.

Neck and shoulder movements are normal.

The following information is on your medical record:

• Past medical history

• Two children, normal pregnancies and delivery

• Vaginal hysterectomy for prolapse aged 45

• Mammogram normal this year

• Medication

• Nil

• Allergies

• Nil

• Immunisations

• Nil known

• Social history

• Non-smoker.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open questions to explore patient’s ideas, concerns and expectations.

Specific questions

Relevant to carpal tunnel syndrome

• — Distribution of paraesthesiae

• — Weakness of thumb movements

• — Symptoms worse at night and early in the morning

Identify possible cause of carpal tunnel syndrome

• — Diabetes, obesity, rheumatoid arthritis, hypothyroidism, employment, hobbies

Exclude other causes

• — Neck or shoulder pathology, OA

• — Malignancy—Pancoast tumour, bone tumour

Request permission to examine.

Examination