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Alicia Fleming: The Case

 

The Case

 

The Case

CC: Pins and needles sensation

HPI: Alicia Fleming is a 21-year-old woman who presents to her OB/GYN physician for a routine 2nd trimester visit. She is 20 weeks pregnant.

She reports a “pins and needles sensation” in her right hand and aching in her right wrist. She states that her sensation started 6 weeks ago without any particular inciting event, is worse at night and when using her phone or computer.  The pins and needles sensation is relieved by “flicking her hand.” She says she finds that she sometimes drops things, especially keys, and has trouble picking up paper.

She added that she has chronic, non-radiating neck pain. No alleviating or exacerbating factors. 

Her left hand and her left and right feet are asymptomatic.


Past medical history: No significant medical history. She is up to date on all her vaccinations.

Past surgical history: None

Medications: Prenatal multivitamins

Allergies: She has no allergies.

Family history: Her mother is 60-years-old and has a 35-year history of diabetes mellitus type 2. Her father is 63-years-old and has a 25-year history of Hashimoto thyroiditis.

Social history: She is married and both she and her husband are students. Alicia has no history of smoking and does not drink alcohol. She reports a sedentary lifestyle as most of her work is done at a computer or driving. As she and her husband do not have health insurance and it is not offered through their school, she is interested in resources that may help pay for medical care. They do not have any income currently and rely on student loans to cover both tuition and room and board.

Review of Systems:

General: No fever, chills or night sweats. 5 pound weight gain. Mild fatigue/weakness.

HEENT: No headaches, no tinnitus, hearing loss or earache. No throat pain, no toothache. No change in vision.

Cardiorespiratory: No shortness of air. No chest pain.

GI: normal bowel movements every 1 to 2 days

Neurological: No dizziness, syncope.

Hematologic: No easy bleeding/bruising.


Physical Examination:

Vital signs: T 98.6 HR 95 BP 130/80 SpO2 99%

General: Pleasant and talkative. Well-nourished, well developed. No acute distress. Alert and oriented. Normal gait.

HEENT: Symmetric facies.

Abdomen: Soft, nontender, nondistended. Fundal height at the level of the umbilicus.

MSK: Cervical range of motion is normal. Mild tenderness to palpation in the bilateral cervical paraspinal areas. Bilateral wrists and fingers with full range of motion. Normal muscle bulk and tone throughout bilateral upper and lower limbs. 

Neurological: Sensation to light touch is impaired over the right thumb, index, long finger and lateral aspect of the ring finger; otherwise sensation to light touch is intact throughout bilateral upper and lower limbs.

Muscle stretch reflexes (DTRs) 2+ at bilateral biceps, triceps and brachioradialis tendons.

Positive carpal compression test on the right, negative on the left. Phalen and reverse Phalen maneuver on the right, negative on the left. Nontender over the cubital tunnels bilaterally. Negative Spurling test bilaterally.

Clinical Librarian

Ansley Stuart's picture
Ansley Stuart
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502-852-8534

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