| CC: | |
| Left third digit numbness and wrist pain. | |
| HX: | |
| This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury. | |
| SHX/FHX: | |
| 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints. | |
| EXAM: | |
| Vital signs unremarkable. | |
| MS: | |
| A & O to person, place, time. Fluent speech without dysarthria. | |
| CN II-XII: | |
| Unremarkable,MOTOR: | |
| 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone. | |
| SENSORY: | |
| Decreased PP in third digit of left hand only (palmar and dorsal sides). | |
| STATION/GAIT/COORD: | |
| Unremarkable. | |
| REFLEXES: | |
| 1+ throughout, plantar responses were downgoing bilaterally. | |
| GEN EXAM: | |
| Unremarkable. | |
| Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left. | |
| CLINICAL IMPRESSION: | |
| Left Carpal Tunnel Syndrome,EMG/NCV: | |
| Unremarkable. | |
| MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent. | |
| COURSE: | |
| The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up. |