Running head: CASE STUDY 1

M.G’s Written Case Presentation

Student’s Name:

Institutional Affiliation:

CASE STUDY

M.G’s Written Case Presentation

Patient ID: M.G. DOB: 09/01/1975

Chief Complaint (CC): “Right-hand pain.”

History of Present Illness (HPI): The patient is a 33-year-old Hispanic female that presents

with right-hand pain for two weeks. Describes pain as achy and intermittent, and it is aggravated

by movement. She rates her pain a 7/10. The pain is relieved by ibuprofen but has recently felt

occasional numbness. She states pain started after they inserted an IV for hysterectomy surgery

4-4-19.

Past Medical History (PMH):

Hypertension

Seasonal Allergies

Sciatica

Hyperlipidemia

Family History: Mom has diabetes, Maternal Grandmother has Diabetes, hypertension,

hyperlipidemia. Father is healthy; Paternal Grandfather has diabetes. 5 Siblings- healthy.

Past Surgical History (PSH):

Hysterectomy 2019

Tonsillectomy 2018

bilateral tubal ligation 2008

Social History (SH): Born in Mexico. Lives in Livingston, CA, with her husband and four

children. She has been happily married for 23 years. Primary language is Spanish, limited

English. She works in the fields. She denies alcohol or drug abuse and goes to church regularly

with her family.

CASE STUDY

Health Care Maintenance: Last physical/pap smear was 1/ 23/2019; the Last dental was

2/26/2019, and the last eye exam 4/2/2019. Up to date on all immunizations except for the Flu

Vaccine, which she declined.

Medications:

Lisinopril 10 mg PO daily

Atorvastatin 20mg PO daily

Zyrtec 10 mg PO daily

Ibuprofen 800 mg PO pPRNpain q 8 hours

Cyclobenzaprine 10 mg PO PRN muscle spasms q HS

Flonase 2 sprays intranasal q day

Medication Allergies: NKDA

Review of Systems (ROS):

General: Denies fatigue, weight loss, fever, or chills.

EYES: Does not wear glasses. Denies itchiness, dryness. The last eye exam was 4/2/2019.

Neck: Denies stiffness or pain. The patient denies a change in ROM.

Cardiovascular: Denies chest pain, edema, or heart palpitations.

Respiratory: Denies shortness of breath, wheezing, cough.

Skin: Denies rashes, swelling, lumps, or bruising easily.

GI: Denies nausea, heartburn, or changes in bowels.

GU: Denies changes in urination, no hematuria.

Neuro: Denies headache, dizziness, and changes in mood, attention, or speech. Denies tremors

or tingling in the arms/legs. Does have intermittent numbness on the right thumb

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Msk: Denies joint pain, swelling, and stiffness. Does have tenderness in the right thumb that

radiates to the foreman. Positive for chronic back pain, radiates below the knee bilaterally,

occasionally back spasms. Left hurts more than right.

Psych: Denies depression, stress, anxiety, or nervousness.

Objective Exam

Ht: 5’1’’ (154 cm) Wt: 130 lbs (58.9 kg) BMI: 24.5

VS: BP-130/76 HR-70 Resp-18 Temp- 36.8*C O2 Sat on RA-98% Pain-7/10

General: Well-dressed and looks her age. Pleasant and well-nourished.

Skin: Skin is pink, warm, well-nourished, no lesions/dryness noted. Nails are smooth, clean, and

short. Cuticles smooth. Capillary refill less than 2 seconds.

Eyes: External eye and eyelids are symmetrical. No redness noted. Lashes clear. EOMs

symmetrical/intact. 3mm brisk pupils. PERRLA bilaterally. No hemorrhaging noted bilaterally.

The red reflex is intact bilaterally. Conjunctiva pink, sclera white. No discharge or exudate.

Neck: No, Lymphadenopathy. Full range of motion. Shoulder shrug symmetrical. No tenderness.

Cardiovascular: Regular rhythm and rate, crisp S1/S2, no murmurs, gallops, or extra heart

tones. Pulses intact.

Respiratory: All lung fields clear to auscultation, no dyspnea. Chest expansion symmetrical

without accessory muscle use, no retractions.

Skin: No ecchymosis, rashes, or swelling.

GI: Bowel sounds, active x4, soft, and non-tender.

Neuro: Alert and oriented x4, DTRs intact, steady gait, and balance. Cranial nerves II-XII intact

CASE STUDY

Msk: 2+ radial pulses bilaterally, right thumb tender to touch, no swelling/ecchymosis. The

weak grip on the right hand. Firm grip on the left hand. Positive Finkelstein test on the right

hand. Negative for Tinel’s sign and Phalen’s test. Left leg positive straight leg raise test, range of

motion within normal limits on the right leg, and left arm.

Psych: Appropriate mood and affect.

Labs did on-site: NA.

Differential Diagnosis:

Possible: De Quervain’s Tenosynovitis, Carpal Tunnel, Tendinitis

Probable: Radial styloid fracture, trigger finger, nerve impingement

Doubt: Ganglion Cysts, ruptured tendon, stroke

Rule Out: Thumb carpometacarpal (OA or RA)

Assessment/Plan

1. De Quervain’s Tenosynovitis ICD-10 code: M64.4

DX: Finkelstein test, palpation of the radial styloid

CASE STUDY

Ibuprofen 800mg tablet q 8hrs PRN pain, Thumb Spica Splint

PT Education: Avoid repetitive movements, rest, keep the splint on, ice (4-6 times a day for 15

mins) take Ibuprofen as directed, and do not exceed 2400mg/day.

F/U: 4-6 weeks. If no improvement, then consider x-ray and referral to an orthopedist or

physical therapy.

1. Chronic midline low back pain with bilateral sciatica ICD-10 code: M54.41

DX: None

RX: Continue taking Ibuprofen 800mg tablet q 8hrs PRN pain, cyclobenzaprine 10mg tablet one

tablet HS PRN.

PT Education: The patient is advised to rest, ice, sciatica stretches, and take Ibuprofen and

muscle relaxer as directed. She is also referred to as Physical therapy.

F/U: 1 month. If no improvement, then consider MRI.

The Rationale for the Assessment Plan

The assessment plan for the patient will help the physicians to adopt the best therapy and

treatment plan. The assessment plan involves differential diagnoses, which either rule in or out

CASE STUDY

different conditions. Therefore, the use of H&PE guidelines, assessment of the red flags, signs,

and symptoms as well as subjective and objective information will help in ruling out or ruling in

possible or probable causes of the pain in the patient’s right hand. The possible causes of the

patient’s chief complaint are De Quervain’s Tenosynovitis, Carpal Tunnel, or Tendinitis. The red

flag signs for De Quervain’s tenosynovitis are that the condition mainly causes pain on the wrist.

Also, this condition affects the wrist’s tendons, which causes the thumb’s swollenness (Hillyard,

Sirisena, Urigo & Sahu, 2018). However, the condition is ruled out since the patient denies

swelling and tenderness.

Similarly, tendinitis is ruled out as the primary cause of pain on the right-hand. The

condition results from a tendon’s irritation or inflammation. The H&PE guidelines state that

tendinitis mostly affects the knees, shoulders, and elbows, and thus, we use these criteria to rule

it out. Another possible cause of pain in hand is the Carpal tunnel (Hackett, Millar, Lam &

Murrell, 2016). The condition causes pain in the entire arm, tingling, and numbness. From the

patient’s chief complaint about the pain in the right hand, tendinitis is ruled in as the potential

cause of her pain. However, the patient denies other red flags such as tingling and numbness,

which are also hallmark signs of tendinitis.

CASE STUDY

From the differential diagnosis, it is also probable that the patient suffers from radial

styloid fracture, trigger finger, or nerve impingement. We rule out the radial styloid fracture

since the condition commonly occurs when styloid is compressed by scaphoid bone. The patient

states that she lives happily with her husband, and therefore we rule out this condition since it is

common with victims of physical violence (Aboonq, 2015). Trigger finger is also ruled out for

this patient. The rationale for ruling out this condition is because it causes stiffness and mainly

occurs on the fingers and not the entire hand. However, the patient denies numbness, and her

pain is not only in the fingers but on the whole right hand. From the subjective data, the patient

might be suffering from nerve impingement since it occurs when a lot of pressure is applied in

the nerves. The patient complains that her pain started when her physician inserted and IV for

hysterectomy surgery. Therefore nerve impingement is ruled in as a cause for her right-hand

pain. Ganglion cysts are ruled out since it forms a fluid-filled lump on the tendon (Tipton,

Alkhafaji, Senehi & Stubbs, 2017). Also, the ruptured tendon is ruled out since the patient denied

a fall from the subjective data exam. The assessment of the subjective data also indicates that the

patient does not have thumb carpometacarpal injury since she did not complain of the thumb

pain.

CASE STUDY

Treatment Plan

The treatment plan for Ms. M.G entails the use of both OTC and Rx medications to

relieve her pain. To help her manage the pain, she needs Ibuprofen 800mg for which should be

taken after every eight hours (Jankowsk et al., 2017). The patient’s medical history also shows

that she has hyperlipidemia, which results in high levels of cholesterol in the blood. Therefore,

Atorvastatin 20mg PO is administered for the patient as a daily dose. The medication will lower

the level of harmful cholesterol for the patient. Notably, the patient should also take a daily dose

of Lisinopril to control her blood pressure since her medical history shows that her maternal

grandmother suffered from hypertension.

The patient admitted that she occasionally suffers from an allergy. Therefore, a

prescription of Zyrtec 10 mg as a daily dose will help the patient to manage the allergy once she

comes across the allergens. A daily dose of cyclobenzaprine 10 mg administered through the

nasal cavity will also help to manage the patient’s allergic condition in case inhaled allergens

cause the condition. The patient agreed that she occasionally experiences numbness on her right

thumb. To manage this condition, she needs to take cyclobenzaprine 10 mg as a daily dose to

calm the muscle spasms.

CASE STUDY

Ms. M.G also requires patient education, which will help her to manage the pain, as well

as other chronic conditions. First, she should increase her physical activity to maintain a healthy

weight to avoid the development of obesity and diabetes since these conditions are in her family

history. Also, the patient should practice healthy eating habits to avoid the buildup of bad

cholesterol, which results in hypertension (Putri, Sofiatin & Roesli, 2017). Secondly, the patient

is advised to take rest, avoid repetitive movements, and use cold ice 4 to 6 times a day. Avoiding

repetitive movement helps the patient to recover faster, while using ice helps to reduce

inflammation. Also, the patient is advised not to exceed 2400mg of ibuprofen medication per

day. Overdose may cause adverse drug events, which reduces the efficiency of other

medications. After two weeks of taking the administered medications, the patient should start

feeling better, and gradual recovery is expected. In case she does not recover, she should go back

to her physician to assess her condition further. M.s M.G’s physician should consider performing

an ultrasound scan for the patient’s hand if the condition deteriorates instead of recovery.

CASE STUDY

CASE STUDY

References

Aboonq, M. S. (2015). Pathophysiology of carpal tunnel syndrome. Neurosciences, 20(1), 4.

Hillyard, K., Sirisena, N., Urigo, C., & Sahu, A. (2018, January). Ultrasound-guided

corticosteroid injections for de Quervain’s tenosynovitis. European Congress of

Radiology 2018.

Hackett, L., Millar, N. L., Lam, P., & Murrell, G. A. (2016). Are the symptoms of calcific

tendinitis due to neoinnervation and neovascularization?. JBJS, 98(3), 186-192.

Jankowski, C. M., Shea, K., Barry, D. W., Linnebur, S. A., Wolfe, P., Kittelson, J., ... & Kohrt,

W. M. (2015). Timing of ibuprofen use and musculoskeletal adaptations to exercise

training in older adults. Bone reports, 1, 1-8.

Jankowski. Arthroscopic Decompression of Greater Trochanteric Sciatic Nerve

Impingement. Arthroscopy Techniques, 6(6), e2203-e2210.

CASE STUDY

Putri, H. A., Sofiatin, Y., & Roesli, R. M. (2017). 74 Patient's Need on Treatment Education of

Hypertension Can Not be Fulfilled in the Consultation Room. Journal of

Hypertension, 35, e11.

Toth, P. P., Worthy, G., Gandra, S. R., Sattar, N., Bray, S., Cheng, L. I., ... & Deshpande, S.

(2017). A systematic review and network meta‐analysis on the efficacy of evolocumab

and other therapies for the management of lipid levels in hyperlipidemia. Journal of the

American Heart Association, 6(10), e005367.