Thursday, January 2, 2014

A Hispanic Mother

A Hispanic Mother

I was working at a rural health clinic in the Eastern hills of Texas when one day a Hispanic female came into be seen.  She was in her 20s, and I found out that she was trying to help support her family of two young kids who’s husband was usually gone being a long haul truck driver.
I knocked on the exam room door and went into introduce myself to a new patient named Maria. 
“Hi, I’m Sharon, I’m the PA who works at this clinic.  How can I help you?”
Through her sister that she used as a Spanish translator, Maria responded, “I’ve got pain and numbness in both of my hands, it comes and goes and I need help.”
“Ok, what do you do day to day?”
“Well I take care of my two young children who are not in school yet, try to keep my house clean, feed my kids and then I work 40 hours a week over at the slaughter house which processes fresh chicken for our grocery stores.”
“What exactly do you do at the slaughter house?”
“I work the line, I take the sliced chicken and make the final cuts into it so that it ends up in nine pieces, which is then packaged and sent out.  So I use my hands all the time.”
“What about at home?”
“My hands are usually numb when I get home, so I end up trying to shake them awake several times every night, which doesn’t work.  By the time I go to bed I usually have pain in one or both of my hands and have to take some Tylenol so as to be able to sleep.”

Risk Factors for Carpel Tunnel Syndrome:
--repetitive actions of the hand or wrist
--sustained hand or arm positions

Usual Symptoms:
--dull, aching discomfort in the hand, wrist or forearm
--numbness in the hand, usually in the first three fingers, sometimes involves the fourth finger (which is the area that the median nerve serves)
--weakness in the hand, clumsiness with grasping objects
--sometimes it helps when the patient shakes their hands, this can sometimes decrease the tingling or pain temporarily

“Is there a spouse in the picture?”
“Yes, but he’s gone the majority of the time.  He works as a long haul truck driver.  He’s only home every few days every other week.”
“Hmm, okay.”
“So let me ask you do you take any medications on a regular basis or are you allergic to any medications?”
Through her translating sister, Maria responded, “No, to both of your questions.”
“Alright, have you had any prior surgeries?”
“Okay, well then let me take a look at your hands and we’ll go from there.”  With that I approached her sitting on the exam table and picked up her left hand and started to palpate it to assess whether she had any abnormal growths or potential hand fractures.  Then I asked her, “where exactly is your numbness and/or pain in your hands when it shows up?”
She pointed to her first three fingers on both hands and then the medial side (inside edge) of her wrists.
"Do you have any tingling or numbness above your wrists?”
“Every once in a while, I’ll get some tingling up my forearms that doesn’t last very long.”
“Ok. Let me see your other hand for a moment.”  Maria handed me her right hand and I palpated it to make sure there wasn’t any abnormality with it.  Once I had determined that she didn’t have any obvious problem with her hands I asked her to put her hands in a totally flexed position (do an internet search for Phalen's test to see pictures of this) that put pressure on her wrists.  I asked her to hold that position for 60 seconds.  Maria was only able to hold the position for 20 seconds before she said her hands had gone numb again. 
Then I asked Maria to hold out her hands and I tapped on her wrist (do an internet search for Tinel test, carpel tunnel syndrome to see how to do this maneuver).  Maria had tingling pain referred down into her hands when I did this, which is a positive test. 
So I knew that Maria had what is called ‘carpel tunnel syndrome’ in both of her hands. 
“Maria, you have what is called ‘carpel tunnel syndrome.  This means that you have tendon swelling in the carpel tunnel area that is pressing down on the nerve that serves your hand and gives it sensation and motor movement.  Your carpel tunnel is right here in the center of your wrist and it is a small round hole through which many of the tendons that start at your elbow come down into your hand.  This is also where the big nerve to your hand, called the median nerve comes down into your hand.  Your tendon(s) are swollen because of all of the repetitive work you do cutting and packaging chicken.”
“So, what do I do about it?” asked Maria.
“Well, usually we can treat it with some Motrin and your wearing wrist braces which will hold your hands/wrist in the most relaxed position for your hands.  You should notice an improvement in your symptoms after a few days, but definitely by the time you come back to see me in two weeks.”
So where do I get the wrist braces?”
“We’ve got them here in the clinic, I’ll go get them and show you how to wear them.”
With that I left the exam room and quickly found the wrist splints for both of her hands in our supply cabinet and came back in and showed her how to wear the splints.  I explained to her that she needed to wear them at night and take prescriptive dose Motrin three times a day.  I told her to make a return appointment to see me in two weeks, which she did. 
Two weeks later she returned to clinic and her symptoms were almost gone, so I advised her to continue to wear the splints at night and to stop the Motrin. 

When I saw Maria in clinic more than 10 years ago it was common practice to use a non-steroidal medication such as Motrin along with the wrist splints which keep the patient’s hands in the most relaxed position possible so as to allow the swelling of their tendon(s) coming through the carpel tunnel area to normalize in size again.  Nowadays there is evidence that Motrin or other non-steroids don’t work and are not recommended.  Instead what is recommended is to use the wrist splints along with systemic steroids, such as prednisone. 
If the wrist splints/prednisone doesn’t work then patients are referred over to a hand surgeon who goes into the carpel tunnel area surgically and enlarges the area of bone involved so that the median nerve, hand tendons have a larger area to travel through on their way to the patient’s hand. 

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