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To enhance your diagnostic reasoning skills, follow these steps:
- Review the Information: Carefully read through the content in each section of the case scenario.
- Consider the Question: Reflect on the Diagnostic Reasoning Question presented. Take your time to think about your answer.
- Compare Your Answer: Attempt to answer the question before viewing our suggested answer. When ready, click “View Suggested Answer” to compare it with your own.
Repeat these steps for each section of the case scenario. Please note that the suggested answers are only indicative and not exhaustive. They serve as guidelines and should not be considered complete answers.
Patient’s History
In the sections below, you will find case history information designed to guide you through a systematic approach to performing a focused and relevant case history. This process will help you narrow down the potential causes of the patient’s complaint. As you go through the material, we encourage you to answer the questions provided to test and enhance your diagnostic reasoning skills.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Jess is a 34-year-old accountant who presents with pain in the anterior aspect of her right hand, primarily affecting the thumb, index and middle fingers. She also reports pain in her right anterior wrist. The symptoms began about four months ago, shortly after she took up a new interest in playing golf.
Diagnostic Reasoning Question
What potential differential diagnoses would you consider for this patient?
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- Carpal tunnel syndrome (median nerve compression at the wrist)
- Pronator teres syndrome (median nerve compression near the elbow)
- Wrist flexor muscle strain or tendinopathy
- Cervical radiculopathy
- Carpal joint dysfunction
Practitioners should always be wary of serious conditions such as infections, fractures, and tumors.
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
Jess describes the pain in her hand and fingers as a 6 out of 10 in intensity at its worst and says that it is always accompanied by numbness and tingling. She reports that all her symptoms become worse after playing a round of golf. Additionally, she has recently started a renovation project, and activities such as painting and using a hammer also aggravate the pain, numbness, and tingling. Her symptoms began gradually but have worsened over time. The pain often wakes her up at night, and when it does, she finds that shaking out her hand helps to relieve the symptoms. Running warm water over her hand also provides relief.
Diagnostic Reasoning Question 1
What is the clinical significance of the patient experiencing pain, numbness, and tingling in her hand and fingers, particularly after activities such as golf, painting, and using a hammer?
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The clinical findings described above indicate a mechanical cause with neurological involvement. The specific activities that worsen her symptoms indicate that repetitive wrist flexion and gripping motions are likely contributing factors.
Diagnostic Reasoning Question 2
How does the patient’s report of symptoms worsening at night and being relieved by shaking out her hand inform the diagnostic process?
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Carpal tunnel syndrome is characterized by worsening symptoms at night and relief by shaking the hand. Nocturnal symptoms are common due to wrist positioning during sleep, and shaking the hand helps to reduce accumulated fluid and decrease pressure on the median nerve.
Are there any associated symptoms?
Upon further questioning, in addition to the pain and sensory disturbances described earlier, Jess also reports a loss of strength in her right hand, making her feel clumsy. She jokes that this has led to some disastrous performances on the golf course and a few renovation mishaps.
Diagnostic Reasoning Question
What is the clinical significance of the patient reporting a loss of strength and clumsiness in her right hand?
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Loss of strength and clumsiness in the hand suggest motor nerve involvement.
Is there any past history that may be relevant to the current complaint?
Jess has no past history of a similar complaint involving her wrist, nor does she have any history of neck or upper extremity injury.
Diagnostic Reasoning Question
How does the absence of a history of a similar complaint inform the diagnostic process?
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The absence of a past history of similar complaints or injuries and the onset of symptoms coinciding with her starting to play golf and beginning a renovation project suggest that the condition is likely due to these new activities rather than the exacerbation of a preexisting condition.
Are there any red flags?
The following questions are asked to identify any “red flags” that could suggest serious pathology. Even if the patient has previously mentioned related information during the case history, it is recommended to revisit these questions to ensure a comprehensive evaluation.
- Do your symptoms disappear even for a short time? “Yes, they did at the beginning. However, more recently, the pain has become quite persistent.”
- Does the pain wake you up at night? “Yes, often.”
- Do you feel weak in your arms? “Yes, I think I have lost strength in my right hand, and I also feel clumsy when using my hand.”
- Have you recently had any fever, chills, or night sweats? “No.”
- Have you had any unexplained weight loss recently? “I’ve lost a little bit of weight, but I put it down to my increased activity.”
- Do you have a history of cancer, inflammatory arthritis, or fracture arising from minor trauma? “No.”
Diagnostic Reasoning Question
Do any of the patient’s answers raise a red flag?
ViewHide Suggested Answer
The patient’s answers raise several potential red flags. The persistence of pain, presence of nocturnal pain, and apparent weakness in the hand could all indicate a serious disorder. However, in this patient, these symptoms are more likely to be clinical features of a mechanical problem causing peripheral compression neuropathy. Nonetheless, practitioners should remain vigilant for the possibility of a more serious disorder, such as a spinal space-occupying lesion, which should be thoroughly explored during the physical examination.
Differential Diagnosis
Diagnostic Reasoning Question
Based on the available history, how would you prioritize the list of differential diagnoses?
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- Carpal tunnel syndrome (median nerve compression at the wrist)
- Pronator teres syndrome (median nerve compression near the elbow)
- Cervical radiculopathy (particularly at the C6 or C7 nerve roots)
- Cervical myelopathy (compression of the spinal cord at the cervical level)
- Brachial plexopathy (neuropathy involving the brachial plexus)
- Carpal joint dysfunction
- Wrist flexor muscle strain or tendinopathy
Reflection Point
Pause and consider whether the key elements of a thorough and relevant patient history have been addressed. Are there any additional questions you would have asked? If so, what are they, and why would they be important?
Before reviewing the physical examination findings below, take a moment to reflect on which physical examination procedures you would perform to accurately assess this patient.
Physical Examination
In the sections below, you will find physical examination findings for this patient. The material outlines a systematic approach to conducting a focused and relevant physical examination aimed at narrowing down the potential causes of the patient’s complaint. As you review the material, we encourage you to answer the questions provided to test and enhance your clinical reasoning and diagnostic skills. Additionally, consider whether all essential elements of the physical examination have been thoroughly addressed.
Vital Signs
Her vital signs are within normal limits.
Diagnostic Reasoning Question
What is the significance of normal vital signs?
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Normal vital signs typically indicate that there are no immediate life-threatening conditions. Particularly, normal temperature indicates the absence of acute infection.
Inspection
On inspection, her wrists appear small and “square-shaped,” with mild atrophy of the right thenar eminence compared to the left. No further abnormalities are detected on inspection of her right elbow, shoulder and neck.
Diagnostic Reasoning Question
What is the clinical significance of small, “square-shaped” wrists and mild thenar eminence atrophy in the context of this patient’s symptoms?
ViewHide Suggested Answer
Anatomically, small wrists with a “square-shaped” appearance (increased depth-to-width ratio) suggest a structural predisposition to carpal tunnel syndrome, as a narrower carpal tunnel can increase the risk of median nerve compression. Thenar eminence atrophy is often observed in more advanced cases of carpal tunnel syndrome, indicating ongoing or severe nerve compression.
Range of Motion
The assessment of the active and passive range of motion of the right wrist, hand, forearm, elbow, shoulder, and cervical spine reveals all movements are within normal limits.
Diagnostic Reasoning Question
What is the clinical significance of her normal range of motion findings?
ViewHide Suggested Answer
The normal range of motion in her upper extremity suggests that the patient’s symptoms are not due to joint dysfunction or localized musculoskeletal issues. This finding supports the hypothesis that the pain and sensory disturbances are likely due to a nerve compression syndrome, such as carpal tunnel syndrome. Additionally, the normal range of motion in her cervical spine makes cervical radiculopathy unlikely.
Palpation
Palpation of her right hand and wrist reveals slight tenderness over the anterior aspect of the wrist. Palpation of her right forearm and the remainder of the right upper extremity is normal, with no tenderness or myofascial trigger points detected. Functional assessment of her right wrist, elbow, shoulder, and cervical spine is also normal.
Diagnostic Reasoning Question 1
What is the clinical significance of slight tenderness over the anterior aspect of her wrist?
ViewHide Suggested Answer
This finding suggests localized inflammation or irritation, which is consistent with carpal tunnel syndrome.
Diagnostic Reasoning Question 2
How does the absence of tenderness in the proximal forearm inform the diagnostic process?
ViewHide Suggested Answer
The absence of tenderness in the proximal forearm helps rule out pronator teres syndrome and other potential causes of median nerve compression at this site.
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Neurological Examination
A neurological screening examination for C5 to T1 nerve roots is performed, revealing no abnormalities.
Diagnostic Reasoning Question
How do the normal neurological examination findings inform the diagnostic process?
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The normal findings help to rule out neurological involvement arising from the cervical spine and brachial plexus. To see a demonstration of a Neurological Screening Examination for C5 to T1 nerve roots, please watch the video below.
A more extensive sensory examination of the right hand is conducted and reveals a loss of sensation over the palmar aspect of the thumb, index, and middle fingers, as well as the lateral surface of the ring finger. Sensation over the thenar eminence is normal. Strength testing of her right thumb abduction and opposition shows it to be slightly weaker compared to the left.
Diagnostic Reasoning Question 1
What is the clinical significance of this pattern of sensory loss and the slight weakness in thumb abduction and opposition?
ViewHide Suggested Answer
The pattern of sensory loss corresponds to the distribution of the median nerve, indicating median nerve compression. The median nerve innervates the thumb, index, and middle fingers, as well as the lateral half of the ring finger, while sparing the thenar eminence. This sparing suggests that the palmar cutaneous branch of the median nerve is unaffected, which is consistent with carpal tunnel syndrome.
The loss of strength in thumb abduction and opposition further supports the diagnosis of median nerve compression at the carpal tunnel.
Diagnostic Reasoning Question 2
What is the significance of normal sensation over the thenar eminence in suspected cases of median nerve entrapment?
ViewHide Suggested Answer
Normal sensation over the thenar eminence indicates that the palmar cutaneous branch of the median nerve is not affected. This finding supports the diagnosis of carpal tunnel syndrome, as the palmar cutaneous branch exits before the nerve enters the carpal tunnel. If the thenar eminence were involved, it would suggest that the median nerve is being compressed proximal to the carpal tunnel (anywhere along the median nerve’s course before it reaches the carpal tunnel).
Reflection Point
Considering the patient’s history and examination findings thus far, take a moment to reflect on which special tests would be most appropriate to further evaluate this patient.
Special Tests
Phalen’s test is performed and found to be positive, reproducing the patient’s symptoms of pain and tingling in the thumb, index, and middle fingers.
Diagnostic Reasoning Question
How does Phalen’s test aggravate the symptoms of carpal tunnel syndrome?
ViewHide Suggested Answer
Wrist flexion during Phalen’s test increases pressure within the carpal tunnel. In patients with carpal tunnel syndrome, where carpal tunnel pressure is already elevated, this additional pressure exacerbates symptoms by further compressing the median nerve.
To see a demonstration of how Phalen’s test is performed, please watch the video below.
The Carpal Compression test is performed and found to be positive, reproducing the patient’s symptoms of pain and tingling in the thumb, index, and middle fingers.
Diagnostic Reasoning Question
What is the clinical significance of a positive Carpal Compression test?
ViewHide Suggested Answer
The Carpal Compression test increases pressure within the carpal tunnel, potentially exacerbating symptoms if the median nerve is compressed. The positive findings in this patient strongly support the diagnosis of carpal tunnel syndrome.
To see a demonstration of how the Carpal Compression test is performed, please watch the video below.
Percussion over the anterior wrist elicits a positive Tinel’s sign, while percussion over the pronator teres muscle does not produce the same response.
Diagnostic Reasoning Question
How do the results of percussion over these two areas contribute to the diagnostic process?
ViewHide Suggested Answer
Tinel’s Sign involves tapping over a nerve to determine if it reproduces symptoms such as tingling or pain. A positive sign indicates irritation or compression of the nerve at the site of percussion.
- Positive Tinel’s Sign at the Anterior Wrist: Suggests median nerve compression at the carpal tunnel.
- Negative Tinel’s Sign over the Pronator Teres Muscle: Helps rule out median nerve compression by the pronator teres muscle near the elbow.
For a demonstration of how these tests are performed, please watch the videos below.
The Resisted Forearm Pronation test is performed and found to be negative.
Diagnostic Reasoning Question
How is the Resisted Forearm Pronation test performed, and what does the negative result in this patient indicate?
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With the patient’s elbow flexed to 90 degrees and their forearm in a neutral position, the examiner stabilizes the patient’s elbow with one hand and positions the other hand on the patient’s wrist. The patient is then instructed to pronate their forearm against the examiner’s resistance. The test is considered positive if the patient experiences pain or tingling in the median nerve distribution during the maneuver.
A negative result in this patient helps rule out the presence of pronator teres syndrome.
For a demonstration of how the Resisted Forearm Pronation test is performed, please watch the video below.
The Valsalva and Maximum Cervical Compression tests are performed and both are found to be negative, with no provocation of the patient’s symptoms.
Diagnostic Reasoning Question
What is the clinical significance of these negative findings?
ViewHide Suggested Answer
A negative Valsalva test in this patient suggests that there is no significant increase in intrathecal pressure due to a space-occupying lesion in the cervical spinal canal. This finding reduces the likelihood of conditions such as cervical disc herniation leading to cervical radiculopathy. The Maximum Cervical Compression test is designed to detect cervical radiculopathy, which occurs when a space-occupying lesion compresses a nerve root. A negative result in this test helps to rule out cervical radiculopathy. Negative results in both tests indicate that the patient’s symptoms are unlikely to originate from the cervical spine. This supports the likelihood of a more distal cause, such as carpal tunnel syndrome or another peripheral neuropathy. For a demonstration of how these tests are performed, please watch the videos below.
Reflection Point
Please pause and assess whether all the essential elements of a thorough and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed? If so, why?
Imaging
The patient is referred for a diagnostic ultrasound, which reveals enlargement of the right median nerve proximal to the flexor retinaculum.
Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Carpal Tunnel Syndrome.
References and Suggested Further Readings
Kothari M. Carpal tunnel syndrome: Clinical manifestations and diagnosis. www. uptodatre.com.
Chompoopong P, Preston DC. Neuromuscular ultrasound findings in carpal tunnel syndrome with symptoms mainly in the non-dominant hand. Muscle Nerve. 2021;63(5):661. Epub 2021 Jan 9..
Ashworth N. Carpal Tunnel Syndrome. Medscape. www.emedicine.medscape.com.
Wipperman J. Carpal Tunnel Syndrome: Diagnosis and Management. American Family Physician. www.aafp.org.
Disclaimer: The acemsk.com website (including text, graphics, downloadable resources, and videos) is intended to provide general health information for educational purposes only. This information is not a substitute for personal consultation with a qualified healthcare professional. Always seek the advice of a healthcare professional for any questions regarding your condition, symptoms, and appropriate treatments.
Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
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