High irritability, low certainty

[cmocarroll]

Recently, I evaled a 54 y/o woman with the only information provided being that she had cervical involvement. The patient denied much neck pain, but described shooting pain down her arm into the 4th/5th digits. With the knowledge that this was listed as a cervical case, I immediately thought about a radiculopathy with C7-T1 nerve root involvement or ulnar involvement, but was curious to know about the referral for neck pain since the patient did not even fill in pain in the cervical region on the body chart. With a few probing questions the patient explained that she did not really think she had much neck pain or neck involvement but her PCP explained to her that it was likely her symptoms were coming from the neck, thus the referral was made that way. The pt did admit that her neck felt sore as well, but it was interesting to me that the PCP had explained the referral to the patient this way because the patient did not seem convinced or like she fully understood. I realized this could be a teaching moment for me if the objective findings seemed to point to radiculopathy. After discussing the body chart, the patient explained that her symptoms started after she tripped and fell onto her R wrist and R knee. The initial pain was so concentrated in these areas that she didn’t realize the arm pain until 2 days after.

With this new information, I realized that there was probably a lot more going on with this case than I was likely to get through during this one visit. The patient described a higher severity of pain and moderate irritability, stating that typically the sharp shooting pain down her arm would diminish in 30 seconds when she stopped the aggravating activity. I was skeptical of this description, knowing that nerves are easily irritated and likely to take more time to calm. As we moved in the objective exam I started to get a little overwhelmed due to the various descriptions of pain the patient reported with each test – “elbow soreness, hand tingling, shoulder soreness, neck aching” each of which was provoked by a different movement but all part of the same pain experience for the patient. By the time I got to the PPIVM/PAIVM assessment I decided to stop the objective exam for the day due to the patient’s increasing irritability and pain with almost all movement testing.

Looking back, part of the exam that caused me to stop and think was when I was going through the cervical radiculopathy criteria and found that cervical distraction was the most provoking symptom and created shooting pain down into the patients 4th/5th digits. This surprised me as I was thinking if this was a radiculopathy that there would be relief. I immediately thought that maybe the distraction force was tractioning the nerve in an area more distal as it leaves the cervical region and courses into the arm. I also hypothesized that maybe the nerve was just overly irritated and thus distraction exacerbated symptoms. I find that often with presentations like this, I have a lot of uncertainty and what seems like conflicting information that I likely need to sort through in a more effective way and not be overwhelmed by. Overall, with this case I felt that I was able to provide the patient with a lot of education regarding neural pathways and what we would do to help her symptoms. It was helpful that the patient had a generally optimistic demeanor and sounded quite motivated to be rid of this pain. I think to truly make sense of the encounter that I will have to continue testing at the next visits. I am thinking that there are multiple factors at play including ulnar nerve irritation, cervical involvement and possible shoulder pathology as well. Due to the nature of the injury, it makes me wonder if there is some possibility for double crush syndrome too. In the future, I need to be more streamlined in my objective measures especially when there is high irritability.

[Author]

Posts