Carpal tunnel syndrome


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor in general surgery

Patient: Nurse has bleeped you to come speak to a 40 year old female patient who has been having hand pain and would like to talk to the doctor about this

Task:

– Take a focused history from the patient

– After 6 minutes you will be asked a series of questions by the examiner.

– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are an 40 year old female patient. You were admitted to hospital today with abdominal pain but that is all being investigated at the moment.

You want to talk to the doctor about your hand, as you were in hospital you thought it would be a good time to get it looked over.

You have been having pain in both hands for the past 6 months which as been at its worst overnight. If asked it is worse in your right hand, which is the hand you write with. You also get the pain when you are driving, reading or brushing your hair.


If asked you have some tingling in your thumb and index finger. Your grip feels like it is weaker than it has been in the past.

It sounds ‘silly’ but if you shake your hand the pain seems to get better. You often wake up with your hand dangled over the side of the bed.

You have seen your GP who thinks it is ‘all in your head’ but you are not stressed about anything in particular at the moment.

PMH

Type 1 diabetic

If specifically asked – you had a wrist fracture in your right hand about 15 years ago

DH

Novomix 30

No known drug allergies

SH

You have never smoked

You drink a glass of rose a week

You live at home with your partner

ICEF

You are worried this is all in your head and you are wasting everyones time.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint
Paraesthesia
Clarifies distribution of paraesthesia (thumb and index finger)
Pain
Weakness


Worsening symptoms
Timing of symptom - worse at night
Driving / reading / brushing hair


Improving symptoms
Improved with hand shaking
Better with hand over bed


Impact on life
Impact on activities of daily living
Impact on job
Impact on social life


Constitutional
Weight loss
Fevers / night sweats
Anorexia


PMH Past medical history
Specifically asks about diabetes
Specifically asks about hypothyroidism
Wrist fracture


DH Drug history
Drug history appropriately asked about
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


FH Family history
Family history appropriately asked about


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question What investigations would you like to do given the history?
Wrist x-ray
FBC, U&Es, LFTs, CRP
TFT
HbA1c
Electromyography (EMG)


Question Given your history what is your most likely diagnosis?
Carpal tunnel syndrome


Question Please run-through what you would be looking for on examination given this patients history?
Looks for deformity/thenar muscle wasting
Wrist active range of movement (ROM)
Wrist passive ROM
Thumb abduction strength
Opposition strength
Tests sensation in digits
Tinnel’s test
Phalens test


Question Given this patient has carpal tunnel syndrome, what are the causes?
Idiopathic
Pregnancy
Obesity
Wrist fracture in the past
Endocrine causes - diabetes, hypothyroidism


Question What are the management options of carpal tunnel syndrome?
Watch and wait
Wrist splint (at night)
Steroid injections (not routinely used)
Surgery: carpal tunnel release



Score