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Solve the Medical Riddle: Her Left Shoulder and Arm Are Painful and Her Fingers Tingle, Second 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.

Last week, the patient reported her symptoms. The doctor proceeded with the examination using the components of the classic S-O-A-P notes, which are as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor referred the patient to a physiatrist, a specialist in non-surgical physical medicine and rehabilitation. The doctor also referred Diane for an X-ray and for magnetic resonance imaging (MRI). This week the physiatrist will continue the quest for a diagnosis of Diane’s condition. 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 begin a new riddle for the following month!

A chest X-ray and cervical spine film revealed no fractures but some arthritis of the neck. Also, Diane did not prove to have a cervical rib, sometimes called a supernumerary or extra rib, that could have made her prone to compression of nerves and resulting pain in her arm. The MRI showed no soft tissue injuries or abnormalities.

The physiatrist used the following tests, called “provocative maneuvers” because they may provoke symptoms:

Wright maneuver: This maneuver requires the patient to hold the arms next to the ears. Paresthesias (tingling or burning sensations) may be noted down the medial scapular (shoulder blades) border and into lower trunk.

 

Elevated-arm stress test: In this test, the patient tries to keep the arms out to the side with flexed elbows for three minutes while flexing and extending the fingers.

Hyperabduction test:The involved arm is raised above the head to find out whether the radial pulse (the one felt on the wrist) is diminished.                            

Military maneuver: Also calledcostoclavicular bracing, this maneuver provokes symptoms when the patient elevates the chin and pulls the shoulder joint behind in an extreme “attention” position.

These physical maneuvers did not reveal appreciable sensory loss or motor atrophy in Diane’s arm.

To be continued . . .

Come back to ThirdAge.com next Thursday to find out what some people have guessed the diagnosis might be.

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