Primary care

10-minute consultation BMJ: first published as 10.1136/bmj.324.7352.1501 on 22 June 2002. Downloaded from Paraesthesia Badal Pal

This is part of a A woman of 45 comes to you with tingling (“pins and Useful reading needles”) and numbness in the fingers and hands. It series of has been getting gradually worse for about three Pal B, Morris J, Keenan J, Mangion P. Management occasional months. of idiopathic carpal tunnel syndrome (ICTS): a articles on survey of rheumatologists’ practice and proposed common guidelines. Br J Rheumatol 1997;36:1328-30. problems in What issues you should cover primary care x Establish which areas are affected. Ask which Helliwell PS. The elbow, forearm, wrist and hand. Baillieres Best Practice and Research in Clinical hand(s) and fingers are affected. Is there pain or Withington stiffness in the shoulder or neck? Are the feet affected Rheumatology 1999;13:311-28. Hospital, Room 10, too? Home 4, Manchester x When do the symptoms occur, and are they worse at M20 2LR night? suggests carpal tunnel syndrome, which affects about Badal Pal x Do cold temperatures worsen the symptoms and consultant 5% of the population. Wasting of the thenar muscle rheumatologist make the fingers change colour (from initial pallor to occurs in under 10% of cases. blue and then red—the triphasic response of Raynaud’s badal.pal@smuht. x Mild carpal tunnel syndrome may not need surgical nwest.nhs.uk phenomenon). decompression. A single injection of corticosteroids x Does using a keyboard or mouse trigger or worsen The series is edited (for example, 20 mg methylprednisolone) into or near by Ann McPherson the symptoms? Ask about machinery at work, particu- the carpal tunnel may improve mild symptoms. Advise and Deborah Waller larly if it causes awkward wrist postures or vibration in the patient to minimise time spent with flexed or The BMJ welcomes the upper limb. extended wrists and to take frequent breaks. A wrist contributions from x Is she taking medicines that may cause paraesthesia, general practitioners splint worn at night for a few weeks or during exacer- to the series such as isoniazid or phenytoin, or those that can cause bating activities may help. Raynaud’s phenomenon, such as â blockers and oral x If the patient is pregnant or obese, reassure her that BMJ 2002;324:1501 contraceptives? carpal tunnel syndrome will probably improve on losing weight. What you should do x Ulnar nerve palsies are much less common. Look

for numbness and tingling in the medial one and a half http://www.bmj.com/ x Briefly examine the upper limbs (and lower limbs, if fingers, and examine for elbow deformities. Symptoms also affected). Test for sensation in the affected areas may be relieved by an elbow splint in extension; more using a fine gauge needle. If the symptoms are not severe cases may need nerve transplantation. present, ask the patient to draw an outline of the x Raynaud’s phenomenon affects 5% of the popula- affected areas when they next occur. tion, 90% of whom are female and young, and is x Cutaneous impairment in the distribution of the usually harmless. If this patient has uncomplicated median nerve (the radial three and a half fingers) Raynaud’s, advise her to wear gloves in cold weather

and to avoid tobacco; she may benefit from on 1 October 2021 by guest. Protected copyright. vasodilators, such as nifedipine 20 mg daily and Phalen’s investigations for paraesthesia in increased slowly as necessary. fingers and hand x Raynaud’s disease (recent onset of the phenomenon in an older person) may be associated with rheumatoid If you suspect: Carpal tunnel syndrome—Do Phalen’s test (positive if arthritis, systemic lupus erythematosus, and sclero- holding the wrist in flexion for 20 seconds or more derma. Check for photosensitivity, rash, mouth ulcera- reproduces the patient’s symptoms) and refer for tion, hair loss, and sclerodermatous changes in the nerve conduction tests hands. If you suspect and subsequently confirm Ulnar nerve palsy—Refer for nerve conduction tests connective tissue disease (see box), explain to the Raynaud’s phenomenon—Test blood for rheumatoid and patient that she needs to see a specialist. antinuclear factors x If the skin goes white in the cold and then red on Other systemic disease—Depending on the findings on neurological examination, consider checking for rewarming, and if the patient works with vibrating hypothyroidism (plasma thyroid stimulating hormone machinery, she may have hand-arm vibration syn- and thyroxine); diabetes (dipstick testing for glycosuria, drome or vibration white finger. She will need occupa- random serum glucose, fasting serum glucose); tional health advice. rheumatoid arthritis and other connective tissue x If the diagnosis is not clear, or there are diffuse disorders (serum rheumatoid and antinuclear factors); symptoms, consider doing a full neurological examina- alcohol related disease (liver function tests, full blood screen); renal disease (urine and blood biochemistry); tion to rule out causes such as peripheral neuropathy vitamin deficiency (serum vitamin B-12 and folic acid); and cervical myelopathy. If there seems to be a simple demyelinating disorders (magnetic resonance explanation such as pregnancy, obesity, or an adverse imaging) drug reaction, reassure the patient and discuss how to cope with the symptoms.

BMJ VOLUME 324 22 JUNE 2002 bmj.com 1501