A 50-year-old secretary named Mildred Payne is in your office complaining of tingling in her left hand. She feels this is an early sign of a
stroke and requests to be seen immediately. Her usual physician is your
partner, who has the day off to testify at a malpractice hearing. The
patient has no appointment scheduled but is making such a scene in
your waiting room that you decide to see her.
Blood pressure 130/80 mmHg
Heart rate 76 beats per minute
Respiratory rate 14 breaths per minute
1. Obtain a focused and relevant history.
2. Perform a focused and relevant physical examination.
3. Discuss your initial diagnostic impressions with the patient.
4. Discuss follow-up tests with the patient.
5. After seeing the patient, complete paperwork relevant to
the case.HISTORYInclude significant positives and negatives from the history
of present illness, past medical history, review of systems, and social
and family history.
Ms. Mildred Payne is a 50-year-old woman who emergently presents
complaining of left-hand tingling. She states that the tingling began
the night before but has been progressively worsening. She states
that the tingling is especially bad in her left middle and index fingers.
Additionally, she feels that her thumb is weak. There is no tingling
in her arm or neck. The other hand is normal. Sleeping and driving
make the tingling worse, but shaking her hand a little alleviates the
symptoms. She denies speech difficulty, vision changes, or any other
numbness, tingling, and weakness. She is employed as a computer
data-entry technician. She denies a history of diabetes mellitus, hypothyroidism, or rheumatoid arthritis.
PHYSICAL EXAMINATIONIndicate only the pertinent positive and negative findings related to the patients chief complaint.
The patient is a very anxious and worried woman who looks her
stated age of 50.
She is concerned that she may be having a stroke.
Neuro: Alert and oriented ×3. CN II-XII normal. Left-handed.
Strength: Weak left thumb flexion, otherwise normal.
Sensory: Decreased sensation to dull and sharp over palmar aspect
of left 1st, 2nd, and 3rd digits.
Positive Tinels sign. Positive Phalens sign.
Rest of sensory examination is normal.
DTR: 2+ diffusely.
228 MASTERING THE USMLE STEP 2 CS
In order of likelihood, write no
more than five differential diagnoses for this patients current
1. carpal tunnel syndrome
2. cervical radiculopathy
3. ulnar neuropathy
4. thoracic outlet syndrome
Immediate plans for no more
than five diagnostic studies.
2. splinting of left hand. S.O.A.P charting