Carpal Tunnel Syndrome
Age: years old
Gender:
HISTORY:
Presents with a - history of hand
Onset was , and occurred
Location is , mostly on the
Radiation to
Rated at / 10
Described as
Pattern , worse during the
Worsening factors:
Alleviating factors: ,
Occupation:
Dominant hand:
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , , , ,
no use of:
EXAM:
Wrist:
Inspection:
Palpation: on
Range of motion:
- Flexion:
- Extension:
- Ulnar deviation:
- Radial deviation:
Sensation: over
Strength: throughout upper extremities, except on
Reflexes: throughout upper extremities, except on
Special tests:
- Phalen test:
- Tinel sign:
- Carpal compression test:
ASSESSMENT:
DDx: carpal tunnel syndrome, ulnar tunnel syndrome at the elbow, Guyon's canal syndrome radial nerve neuropathy, cervical radiculopathy, peripheral neuropathy, Raynaud's phenomenon, thoracic outlet syndrome, tendonitis, de Quervain's tenosynovitis, flexor tenosynovitis, osteoarthrosis, diabetic neuropathy, vascular insufficiency, complex regional pain syndrome, ganglion cyst, alcohol-related neuropathy, hypothyroidism
PLAN:
Investigations:
- Nerve conduction study
- EMG
- X-ray of the wrist
- MRI of the wrist
- Blood work: , , ,
Treatments:
- Wrist splint
-
-
- Corticosteroid injection
- Physical therapy
- Occupational therapy
Further care:
- Referral to neurologist
- Referral to orthopedic surgeon
- Referral to plastic surgeon
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as weakness or atrophy, or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Wrist: ASSESSMENT: PLAN: