Solve the Medical Riddle: Her Left Arm Is Painful and Her Fingers Tingle, First Week
Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.
We’ll start this week by letting you know what the patient told the doctor and how the doctor proceeded with the examination. Next week, a specialist will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the specialist will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!
The Patient Reports Her Symptoms
Diane, a 59-year-old divorced empty nester, woke up one morning with pain in her left arm plus a tingling sensation in the fingers of her left hand.
As always in ThirdAge Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
A=Assessment or Analysis
P=Treatment Plan or Recommendations
This week, we’ll learn what Diane told the doctor:
“Thank you for fitting me into your schedule on such short notice. The reason I walked in without an appointment is that I’ve heard that having pain in your left arm can be a symptom of a heart attack. I thought I’d better see you right away. I live alone now that I’m divorced and the kids are grown so I kind of panicked at the thought of being in the house by myself and having a heart attack. I don’t really think that would have happened, though. I’m left-handed and I started taking tennis lessons for the first time in my life three weeks ago. I might have pulled something. I hope that’s all that’s wrong and that the pain goes away soon! Right now, I can’t lift my arm over my head or anywhere close to that height. This morning I couldn’t get my coffee mug off the shelf with my left hand. I had to use my right hand.
“That’s not the end of the world, I know, but being unable to use my dominant arm and hand normally really is a nuisance. I had trouble putting on my clothes when I was getting ready to come here, and I can’t carry my purse on my left shoulder the way I usually do.
“Also, my job as an elementary school secretary involves a lot of typing on a computer. I called in sick today so I haven’t tried to type yet but I’m pretty sure it will be difficult. Did I mention that the fingers of my left hand feel tingly and cold off and on? I’m usually a very fast touch typist but this condition, whatever it is, will surely slow me down. Do you have any idea what might be wrong with me?”
In spite of the fact that Diane is left-handed and may therefore have pain in her left arm because of overuse, the doctor began by ruling out serious causes of left arm numbness including coronary disease, pulmonary emboli, and acute vascular blockage of an artery or vein in left arm. A 59-year-old woman with left arm numbness or any other concern or vague symptoms of coronary artery disease (CAD) should have CAD and other serious conditions ruled out quickly.
Diane’s doctor immediately sized up her risk factors for heart disease and other serious conditions. The result was good in that Diane doesn’t smoke, doesn’t have high blood pressure, doesn’t have high cholesterol and both parents died of cancer in their early eighties rather than of heart disease at a younger age. In addition, Diane was not on hormone therapy, which can raise the risk of blood clots.
Next, the doctor asked in detail about Diane’s symptoms in order to ascertain that the pain was not related to exertion. The classic worrisome symptoms of CAD requiring urgent evaluation are shortness of breath and the fact that rest does relieve the pain. Diane said she had no shortness of breath although the pain was somewhat relieved by rest. Angina or exertional chest pain is relieved by rest. Only a heart attack with persistent pain would not be relieved by rest.
A quick exam revealed that Diane had no swelling or redness and that she had a normal pulse and normal capillary refill of her fingers, thus showing no acute vascular or coronary event. Also, an in-office electrocardiogram (EKG) and heart exam were normal.
After the life-threatening conditions were excluded, the doctor took more time to rule out the underlying cause with a detailed history. He asked Diane to describe the pain location and type on a pain diagram with a front, back, and side view of the human body. She indicated pain and numbness of the whole arm and tingling in her fingers. She described the pain as dull and aching.
The doctor then referred Diane to a physiatrist, a specialist in non-surgical physical medicine and rehabilitation, and recommended an X-ray and magnetic resonance imaging (MRI) to rule out fractures and soft tissue injuries . . .
To be continued . . .
Come back to ThirdAge.com next Thursday to learn how the physiatrist continued the quest for a correct diagnosis of Diane’s condition . . .
Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Pleas visit DrSavard.com.