1. Step 6
1.1. Review session 1
1.1.1. Summary of step 5
1.2. Report new knowledge
1.2.1. Review anatomy upper limb (breifly)
1.2.1.1. mucles of fine movements
1.2.1.2. Innervations
1.2.2. What causes these symptoms in hand workers?
1.2.2.1. is it ligament, muscle, or nerve injury?
1.2.3. Why burinign - tingling sensation?
1.3. Pictures
1.3.1. Brachial plexus
1.3.2. Cross section of wrest
1.3.3. Median nerve sensory territory
1.3.4. Structures involved in CTS
1.3.5. Hand symptom diagram
2. Step 7
2.1. Inquiry plan and info gathering
2.1.1. History of presenting complain
2.1.1.1. No injury
2.1.1.2. gradually increasing
2.1.1.3. No edema
2.1.1.4. Shacking relives it
2.1.1.5. Takes sometimes pain killers and some work
2.1.1.6. She wakes from the pain at night
2.1.1.7. Worsening by working
2.1.1.8. Shaky hands at the end of the day (weakness)
2.1.1.9. At night 7 or 8 from 10
2.1.2. Previous medical / surgical history
2.1.2.1. No bone or joint problems before
2.1.2.2. No hypothyrodism
2.1.2.3. No surgery
2.1.2.4. She is not pregnant now
2.1.2.5. No chronic diseases
2.1.3. Drug history / allergy
2.1.3.1. Panadol
2.1.3.2. Prophine (works)
2.1.3.3. No allergy
2.1.4. Family history
2.1.4.1. No history of arthritis in family
2.1.4.2. Both parents are diabetic
2.1.4.3. Her dad had symptoms in both legs and hands (she's not sure if it's the same things)
2.1.5. Social / occupational history
2.1.5.1. She drinks occasionally
2.1.5.2. She doesn't smoke
2.1.5.3. She lives alone
2.1.5.4. Eats will
2.1.5.5. She goes walking for sport on weekend
2.1.5.6. She is not comfortable in work and afraid that she will lose her job
2.1.5.7. Sleep deprived also because of this
2.1.6. Physical examination
2.1.6.1. Muscle wasting in the thenar emenice
2.1.6.2. No lesions or swellings
2.1.6.3. Phalen and Tinel are positive
2.1.6.4. Weakness of thumb opposition
2.1.6.5. Normal reflexes
2.1.6.6. Grip is normal
2.1.6.7. 2 point discrimination is comparable
2.1.6.8. No bone deformities
2.1.6.9. No acromegaly
2.1.6.10. BMI 32
2.1.6.11. No restriction in movement (flexion or extension)
2.1.6.12. sensory
2.1.6.12.1. light touch
2.1.6.12.2. deep touch
2.1.6.12.3. do not feel well in the palmer aspect of the thumb, index, and middle finger
2.1.7. tests results
2.1.7.1. Sensory Nerve Conduction Studies +
2.1.7.2. Motor Nerve Conduction Studies +
2.1.7.3. Sugar 160 2 hours after a meal
2.1.7.4. vital signs normal
2.1.7.5. x-ray of spine is normal
2.1.7.6. normal ex-ray of the hand
2.1.7.7. obese (BMI 32)
3. Step 8
3.1. Diagnostic decision
3.1.1. Severe Carpal tunnel syndrome
3.2. Mechanism
3.2.1. Multifunctional
3.2.1.1. repetitive use of the hand
3.2.1.2. Obesity
3.2.1.3. Genatic predisposition
3.2.1.3.1. Female sex
3.2.1.3.2. Father history
3.2.2. Compression of the carpal tunnel
3.3. Presentation
3.3.1. parasthersia in the lateral 3 fingers of the hand radiating to the forearm and upper limb
3.3.2. Muscle wasting
3.3.3. Fine movement affected (buttoning up)
3.3.4. Increases with sleep and after work
3.3.5. Relived by shacking
3.4. Supporting data
3.4.1. Sensory Nerve Conduction Studies +
3.4.2. Motor Nerve Conduction Studies +
3.4.3. BMI 32
3.4.4. sensory
3.4.4.1. light touch
3.4.4.2. deep touch
3.4.4.3. do not feel well in the palmer aspect of the thumb, index, and middle finger
3.4.5. Phalen and Tinel are positive
3.4.6. Muscle wasting in the thenar emenice
3.4.7. Sugar 160 2 hours after a meal
3.4.8. Weakness of thumb opposition
3.4.9. Normal reflexes
3.5. For next time:
3.5.1. How to determine axonal loss
3.5.2. Sensitivity and specificity of the tests