Module 3 Discussion
This week started quite well from my point of view, perhaps not as well from my preceptor’s point of view. The office was open on Monday, July 5, and even though every appointment was confirmed the Friday before, more than a third of them did not show for their scheduled appointments. I actually enjoyed the extra time that I was able to spend with the patients and with the doctor. The extra time with the patients allowed me to not feel as if we were rushing through to the next patient, and I felt as if I were able to think more critically about the patient in front of me. My preceptor is comfortable enough in handing over his notebook and letting me go interview the patient and initiate their encounter, and I feel even more confident this week than I have in the past weeks. The extra time that was afforded to me with the doctor allowed me to pick his brain with my list of questions and “what if” scenarios. I feel I have gained so much additional knowledge being able to ask questions of someone who has been in the medical field for 30 years. His experiences will never be my experiences, but the wealth of knowledge that is shared provides a great reference point.
One particular patient this week presented to the office for pain in his right hand. He was a 59-year-old gentleman who currently has his own construction business. They have been very busy, and he has been helping out with a lot of the physical labor this past year. He complained of numbness and tingling in his (dominant) right hand when grabbing and using tools for the past 2-3 months. He states he came in today because he actually dropped one of his power tools due to the tingling sensation a few days ago. His vitals were T: 98.2 *F tympanic, PR: 68, RR: 16, BP: 117/68 L arm sitting, O2: 100% on RA. He does not actively have pain in the wrist, only the numbness and tingling. A focused assessment on his shoulders, and arms revealed no significant findings. When I assessed his bilateral hands and wrists and performed a modified carpal compression test, the patient actually jumped a little in his seat, and grimaced. This test is easily performed by having the patient sit across from you and hold his hands out in front of him, palms up, then you place pressure on the median nerve, while flexing his hands upward and towards him and holding for 20-30 seconds. If the patient experiences the numbness, tingling or pain, it is considered a positive test for carpal tunnel syndrome.
The plan of care for this patient was to refer him out for an x-ray of his bilateral wrists, to rule out osteoarthritis, and for nerve conduction studies. While he awaited the insurance approval, it was recommended that he wear a wrist splint, that can stabilize his hand into a neutral position, especially at night. Naproxen 500mg PO BID was ordered for the patient at this time. Carpal tunnel syndrome (CTS) is sometimes caused by physical occupational activities, such as repetitive and forceful movements of the hand and wrist or use of hand-held, powered, vibratory tools. The dominant hand is more frequently affected by CTS, (Yunoki et al., 2017). The best suggested nonsurgical treatments for CTS are to avoid the positions that overextend the wrist, taking anti-inflammatory pain medications, and wearing wrist splints to keep your hand in a neutral position (HealthLine, 2019). Sometimes it may require additional therapies to heal CTS that can include physical therapy, steroid injections into the carpal tunnel, or surgical intervention (HealthLine, 2019). Possible differential diagnoses for this patient include osteoarthritis and tenosynovitis. Osteoarthritis presents with pain and stiffness in the joints that becomes worse after exercise or pressure on the joint; rubbing, grating, or crackling sounds can be heard when a joint is moved; morning stiffness at the joint; and pain that causes sleep disturbances (Nichols, 2017). Tenosynovitis presents with joint stiffness that makes it difficult to move; joint swelling, pain, and tenderness; and redness of the skin that overlies the tendon affected (Burke, 2019).
From this week’s experience I learned a few things. From a business standpoint, sometimes your lesser successful financial days can bring more personal satisfaction by allowing for extra time spent with the patient. I think this is the reason that my week started so well. I was able to spend more time with the patients that we saw, and felt that it offered me a better learning experience from the student aspect. The doctor himself was not that happy that so many of his patients did not show up, but he does a have a business to run, and expenses he needs to meet. I also learned that we are going to have to adapt to situations that arise in our days that we have no control over. In understanding that days like this will occur, we should appreciate the little unexpected breaks we get from the hectic pace of the work day.
Burke, D. (2019, March 8). Tendon sheath inflammation (Tenosynovitis). https://www.healthline.com/health/tenosynovitis
HealthLine. (2019, March 7). Carpal tunnel syndrome. https://www.healthline.com/health/carpal-tunnel-sy…
Nichols, H. (2017, November 14). What are the causes and types of arthritis? https://www.medicalnewstoday.com/articles/7621
Yunoki, M., Kanda, T., Suzuki, K., Uneda, A., Hirashita, K., & Yoshino, K. (2017). Importance of recognizing carpal tunnel syndrome for neurosurgeons: A review. Neurologia Medico-Chirurgica, 57(4), 172–183. https://doi.org/10.2176/nmc.ra.2016-0225