A 50-year-old secretary named Mildred Payne is in your office complaining of tingling in her left hand. She feels this is an early sign of a
stroke and requests to be seen immediately. Her usual physician is your
partner, who has the day off to testify at a malpractice hearing. The
patient has no appointment scheduled but is making such a scene in
your waiting room that you decide to see her.
Vital Signs:
Temperature 98.6°F
Blood pressure 130/80 mmHg
Heart rate 76 beats per minute
Respiratory rate 14 breaths per minute
Examinee’s Tasks
1. Obtain a focused and relevant history.
2. Perform a focused and relevant physical examination.
3. Discuss your initial diagnostic impressions with the patient.
4. Discuss follow-up tests with the patient.
5. After seeing the patient, complete paperwork relevant to
the case.HISTORY—Include significant positives and negatives from the history
of present illness, past medical history, review of systems, and social
and family history.
Ms. Mildred Payne is a 50-year-old woman who emergently presents
complaining of left-hand tingling. She states that the tingling began
the night before but has been progressively worsening. She states
that the tingling is especially bad in her left middle and index fingers.
Additionally, she feels that her thumb is weak. There is no tingling
in her arm or neck. The other hand is normal. Sleeping and driving
make the tingling worse, but shaking her hand a little alleviates the
symptoms. She denies speech difficulty, vision changes, or any other
numbness, tingling, and weakness. She is employed as a computer
data-entry technician. She denies a history of diabetes mellitus, hypothyroidism, or rheumatoid arthritis.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint.
The patient is a very anxious and worried woman who looks her
stated age of 50.
She is concerned that she may be having a stroke.
VS: Normal.
Neuro: Alert and oriented ×3. CN II-XII normal. Left-handed.
Strength: Weak left thumb flexion, otherwise normal.
Sensory: Decreased sensation to dull and sharp over palmar aspect
of left 1st, 2nd, and 3rd digits.
Positive Tinel’s sign. Positive Phalen’s sign.
Rest of sensory examination is normal.
DTR: 2+ diffusely.
228 MASTERING THE USMLE STEP 2 CS
DIFFERENTIAL DIAGNOSIS
In order of likelihood, write no
more than five differential diagnoses for this patient’s current
problems.
1. carpal tunnel syndrome
2. cervical radiculopathy
3. ulnar neuropathy
4. thoracic outlet syndrome
5.
DIAGNOSTIC WORKUP
Immediate plans for no more
than five diagnostic studies.
1. electromyography
2. splinting of left hand. S.O.A.P charting
How to solve
Charles Drew University 50 Year Old Woman with Hand Tingling Essay
Introduction:
Based on the given case description, the patient, a 50-year-old woman named Mildred Payne, presents with complaints of tingling in her left hand. She believes this may be an early sign of a stroke and requests immediate attention. As her regular physician is unavailable, I have decided to see her. The vital signs are within normal range, and a focused and relevant history and physical examination will be carried out. Initial diagnostic impressions will be discussed with the patient, and appropriate follow-up tests will be recommended. Necessary paperwork will also be completed after the patient visit.
Answer to Question 1: Obtain a focused and relevant history.
Key Points from the History:
– Patient: Ms. Mildred Payne, 50-year-old female
– Chief complaint: Tingling in the left hand
– Duration: Started the night before and progressively worsening
– Distribution: Primarily affects the left middle and index fingers
– Associated findings: Weakness in the left thumb
– Absence of symptoms in the arm or neck
– Exacerbating factors: Sleeping and driving
– Alleviating factors: Shaking her hand
– No speech difficulty, vision changes, or other numbness or weakness
– Occupation: Computer data-entry technician
– No history of diabetes mellitus, hypothyroidism, or rheumatoid arthritis
Answer to Question 2: Perform a focused and relevant physical examination.
Key Findings from the Physical Examination:
– Patient appears anxious and worried
– Vital Signs: within normal limits
– Neurological Examination: Alert and oriented, normal cranial nerves (II-XII)
– Left-handed
– Strength: Weakness in left thumb flexion, otherwise normal
– Sensory Examination: Decreased sensation to dull and sharp in the palmar aspect of the left 1st, 2nd, and 3rd digits
– Positive Tinel’s sign and Phalen’s sign
– Rest of sensory examination is normal
– Deep tendon reflexes (DTR): 2+ diffusely
Answer to Question 3: Discuss your initial diagnostic impressions with the patient.
Based on the history and physical examination findings, the initial diagnostic impressions for Ms. Mildred Payne’s current problems are as follows:
1. Carpal tunnel syndrome
2. Cervical radiculopathy
3. Ulnar neuropathy
4. Thoracic outlet syndrome
Answer to Question 4: Discuss follow-up tests with the patient.
The following diagnostic tests are recommended for further evaluation:
1. Electromyography (EMG)
2. Splinting of the left hand
Answer to Question 5: After seeing the patient, complete paperwork relevant to the case.
As the medical professional in charge of Ms. Payne’s case, appropriate documentation will be completed, including SOAP charting, which includes subjective, objective, assessment, and plan sections. This documentation will accurately reflect the patient’s presenting complaints, examination findings, differential diagnoses, and recommended follow-up tests.
