Mrs. a Is a Pleasant, 45 Year Old, Black, Female

7/7/11 10:45 am Mrs. A is a pleasant, 45 year old, black, female

She came into my office today complaining that “The fingers on my right hand have a crazy feeling.”

Patient states that she began noticing that her right hand felt “crazy” when she awakened in the morning. This symptom began about one month ago and has progressively gotten worse, therefore she decided to come to the office today. One month ago the “crazy” feeling in the right hand was a 2 out 10 in its intensity of feeling odd, but today the patient rates it a 6 out of 10. She states that the symptoms come and go in a daily pattern. Every morning when she gets up her right hand feels “crazy” and she has to shake her hand (like it is asleep) to get it feeling more like normal. The symptom is the worse in the early morning upon awakening and alleviates itself by mid morning (9am) and then it feels normal for the rest of the day. Sleeping seems to be the only thing that provokes the symptom. The symptom does not radiate to any other location. The patient does not know what is causing this “crazy feeling” but has come to the office today to find out why it is happening. The patient states that it is not affecting her work now but is afraid that it might in the future if the symptoms get worse and/or they become permanent.

Patient states that she has suffered from high blood pressure for about 4 years, ever since she gave birth to her 5th child. She is taking metformin at 1000 mg per day by mouth and Vitamin D 1000 I/U by mouth daily.

Patient also works full time as an administrative assistant at a high school and spends about 6 hours a day at a computer and works 40 hours a week. Patient states that she remembers her mother complaining of something odd happening in her hand several years ago but her mother has since died and she doesn’t know what caused the odd feeling in her mother’s hand. Her mother died of breast cancer at 65 years of age.

Regularly receives flu vaccines. Screening tests: Patient visited the opthalmologist in 2010. Patient keeps regular visits to the dentist and has an appointment at the end of the month. Her last mammogram was completed in February 2011 and PAP completed September 2010. Patient had a colonoscopy screening in 2009 with a 10 year follow up recommended.

Patient does not smoke, drink alcohol, or use illegal drugs. Exercise & Diet: Patient does not have a regular exercise routine. Patient states that she eats the school prepared breakfast and lunch daily during the week. For dinner, she eats at home, often times a frozen dinner for one.

Patient reports morning weakness and a “crazy” feeling to her 1st, 2nd, and 3rd fingers on her right hand, without numbness, tingling, or pain. No abnormal sensation to the right thumb or pinky. No abnormal sensation to left hand, wrist, or fingers.

VS – BP:160/80, HR: 72, RR: 18, Temp 98.4, weight: 228, height: 72 inches, BMI:31. Mrs. A is alert and awake, and responding appropriately. Afebrile. Skin warm and dry. Lungs clear to auscultation, without crackles, wheezes or rhonchi. Normal S1 & S2 without any splits, skips, rubs, gallops, or murmurs. Bilateral wrist, hand, and fingers without deformity or swelling, full ROM demonstrated, no Thenar atrophy in median nerve compression, no tenderness to palpation, radial pulses 2+ brisk and normal, capillary refill <2 sec., hand grip strength strong and equal bilaterally. Positive Tinel’s and Phalen’s sign, patient complained of slight funny feeling in the right second, third, and forth fingers after performing tests.

Problem #1 –Right Hand Feels Funny.

Most Likely Diagnosis #1 – Carpel Tunnel Syndrome because the patient presents with numerous risk factors for having the diagnosis, including female sex, age between 40 and 60 years old, and high BMI. Symptoms normally present in the first three fingers as the patient complained of. Symptoms also become worse at night causing her to feel a “crazy” feeling in the right hand/1st-3rd fingers upon awakening. Additionally, hypothyroidism is frequently associated with this condition. Finally, she had a positive Tinel’s and Phalen’s sign which suggest carpel tunnel syndrome.

Other possible causes of symptoms -Osteoarthritis -Stroke