NU566 Unit 7 Journal

NU566 Unit 7 Journal

Student Name

Purdue University Global

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

Prof. Name:

Date

NU566 Unit 7 Journal

Carpal tunnel syndrome is one of the most common nerve compression disorders affecting the hand and wrist, particularly among individuals who perform repetitive manual tasks. This case study examines a 68-year-old male presenting with progressive right-hand weakness, wrist pain, and reduced grip strength. The patient’s symptoms, occupational history, physical examination findings, and diagnostic assessment strongly support a diagnosis of carpal tunnel syndrome. This comprehensive nursing case study highlights the importance of early assessment, differential diagnosis, and evidence-based management to prevent permanent median nerve damage and improve hand function.

Patient Information

Chief Complaint

Mr. Moses Sinclair presented with increasing weakness in his right wrist and hand. He reported frequently dropping objects while performing daily activities and expressed concern that his hand strength had gradually declined over the previous three months.

His primary complaints included:

• Persistent right wrist weakness

• Difficulty maintaining grip strength

• Frequently dropping objects

• Aching pain in the right hand that worsens with activity

These symptoms significantly interfered with his work as a tailor, where repetitive hand movements are essential.

History of Present Illness (HPI)

Mr. Sinclair is a 68-year-old African American male who sought medical evaluation because of progressive pain and weakness affecting his dominant right hand. According to the patient, the symptoms began approximately three months before the visit and have gradually worsened over time.

He described the discomfort as a dull, aching pain localized primarily to the wrist and hand. The pain becomes more noticeable during activities requiring repetitive hand movements, particularly sewing and prolonged gripping. Gentle massage and Extra Strength Tylenol provide temporary relief.

When asked to rate his pain using the standard numerical pain scale, he reported a severity of 6 out of 10.

Several clinical features raise suspicion for median nerve compression, including:

• Progressive loss of grip strength

• Difficulty holding objects

• Activity-related wrist pain

• Gradual symptom progression

• Temporary relief with rest and analgesics

Given his occupation as a tailor, prolonged repetitive wrist movements represent a significant occupational risk factor for developing carpal tunnel syndrome.

Current Medications

The patient reported taking the following medication:

He denied taking any additional prescription medications.

Allergies and Medication Intolerances

Mr. Sinclair reported no known medication allergies.

However, he experiences gastrointestinal discomfort after taking ibuprofen, which limits its use for pain management.

Past Medical History

The patient denied having any significant chronic medical conditions.

He also denied:

• Previous hospitalizations

• Major surgeries

• Serious traumatic injuries

• Long-term medical illnesses

Overall, his medical history is largely unremarkable.

Family History

A review of the patient’s family history revealed several notable health conditions.

Although these conditions are not directly responsible for the patient’s current wrist symptoms, they remain important considerations during routine preventive health screening.

Social History

Mr. Sinclair currently works as a tailor, a profession that requires continuous fine motor activity, repetitive wrist movements, gripping, and prolonged hand positioning. These occupational demands substantially increase the risk of repetitive strain injuries such as carpal tunnel syndrome.

He lives with his wife in a two-story condominium and reported feeling safe in his home environment. The couple has no children.

Regarding lifestyle habits:

• Denies tobacco use

• Denies illicit drug use

• Drinks approximately one glass of wine with dinner

• Remains independent in activities of daily living

Overall, his social history identifies occupational repetitive hand use as the most significant contributing factor to his current condition.

Review of Systems (ROS)

A comprehensive review of systems was performed to identify additional symptoms that could contribute to the patient’s diagnosis or indicate underlying systemic disease.

General

The patient denied:

• Fever

• Chills

• Fatigue

• Night sweats

• Weight loss or gain

• Decreased energy levels

Cardiovascular

He denied experiencing:

• Chest pain

• Palpitations

• Orthopnea

• Paroxysmal nocturnal dyspnea (PND)

• Peripheral edema

Respiratory

The patient denied:

• Shortness of breath

• Wheezing

• Persistent cough

• Hemoptysis

• History of tuberculosis

• Previous episodes of pneumonia

Skin

No dermatological concerns were reported.

He denied:

• Skin rashes

• Delayed wound healing

• Bruising

• Bleeding abnormalities

• Changes in moles or skin pigmentation

Eyes

The patient denied:

• Blurred vision

• Visual disturbances

• Corrective lens use

• Recent changes in eyesight

Gastrointestinal

He denied symptoms including:

• Abdominal pain

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Peptic ulcers

• Hemorrhoids

• Hepatitis

• Black or tarry stools

Ears

The patient denied:

• Hearing loss

• Ear pain

• Tinnitus

• Ear discharge

Genitourinary

Mr. Sinclair denied:

• Dysuria

• Urinary urgency

• Urinary frequency

• Hematuria

• Changes in urine color

He reported being sexually active but not using contraception. Although he denied any known prostate problems, he acknowledged being overdue for a routine prostate examination.

Nose, Mouth, and Throat

The patient denied:

• Nosebleeds

• Nasal congestion

• Sinus infections

• Difficulty swallowing

• Hoarseness

• Dental disease

• Persistent sore throat

Musculoskeletal

The musculoskeletal review identified several clinically significant findings.

The patient reported:

• Right wrist pain

• Limited wrist mobility

• Neck pain and stiffness

• Decreased pinch strength

• Positive Phalen’s test

• Positive Tinel’s sign

He denied:

• Back pain

• Previous fractures

• Osteoporosis

These findings strongly support compression of the median nerve and are highly consistent with carpal tunnel syndrome.

Neurological

The patient acknowledged weakness involving his right hand but denied other neurological symptoms, including:

• Seizures

• Syncope

• Temporary paralysis

• Paresthesia

• Blackout episodes

Hematologic, Lymphatic, and Endocrine

Review of this system was largely unremarkable.

The patient reported:

• HIV negative status

He denied:

• Swollen lymph nodes

• Easy bruising

• Previous blood transfusions

• Night sweats

• Excessive thirst

• Increased appetite

• Heat intolerance

• Cold intolerance

Psychiatric

The patient denied any history of:

• Depression

• Anxiety

• Sleep disturbances

• Suicidal thoughts

• Previous psychiatric diagnoses

His responses suggested normal mood, appropriate affect, and good psychological well-being.

Objective Assessment

A comprehensive physical examination was performed to evaluate the patient’s overall health and determine the underlying cause of his right wrist pain and hand weakness. The assessment included vital signs, a detailed head-to-toe examination, musculoskeletal evaluation, neurological assessment, and laboratory investigations. Overall, the patient appeared healthy and medically stable, with abnormalities primarily localized to the right wrist and hand.

Vital Signs

The patient’s vital signs were within normal limits, indicating hemodynamic stability and the absence of acute systemic illness.

Although the patient’s body mass index (BMI) places him in the overweight category, his cardiovascular and respiratory parameters remained stable throughout the examination.

General Appearance

Mr. Sinclair appeared as a healthy, well-groomed older adult in no acute distress. He was alert, oriented to person, place, and time, and responded appropriately to all questions. Throughout the examination, he remained attentive, cooperative, and demonstrated no signs of cognitive impairment or emotional distress.

Skin Assessment

Inspection of the skin revealed normal findings.

The patient’s skin was:

• Brown in color and consistent with his ethnicity

• Warm and dry

• Clean and intact

• Free of rashes, lesions, ulcers, or discoloration

No evidence of infection, inflammation, or delayed wound healing was observed.

Head, Eyes, Ears, Nose, and Throat (HEENT)

The HEENT examination showed no abnormalities.

Head

The head was normocephalic and atraumatic, with evenly distributed hair and no visible lesions or deformities.

Eyes

Ocular examination demonstrated:

• Pupils equal, round, reactive to light and accommodation (PERRLA)

• Extraocular movements (EOMs) intact

• No conjunctival injection

• No scleral icterus

• Normal visual inspection

Ears

Both ear canals were patent.

Additional findings included:

• Pearly gray tympanic membranes

• Positive light reflex bilaterally

• Clearly visualized anatomical landmarks

• No drainage or inflammation

Nose

The nasal examination revealed:

• Pink nasal mucosa

• Normal turbinates

• No septal deviation

• No drainage or congestion

Oral Cavity and Pharynx

The oral examination showed healthy mucous membranes and good oral hygiene.

Findings included:

• Pink, moist oral mucosa

• Non-erythematous pharynx

• No tonsillar exudate

• Teeth in good repair

Neck

Neck examination was unremarkable.

The patient demonstrated:

• Full range of motion

• Supple cervical spine

• No cervical or occipital lymphadenopathy

• No thyroid enlargement or palpable nodules

Cardiovascular Examination

The cardiovascular assessment revealed normal heart function.

Key findings included:

• Regular heart rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs

• No rubs

• No gallops or extra heart sounds

• Capillary refill approximately two seconds

• Peripheral pulses graded 3+ bilaterally

• No peripheral edema

These findings suggest adequate peripheral circulation and normal cardiac function.

Respiratory Examination

Respiratory assessment was within normal limits.

The patient’s examination demonstrated:

• Symmetrical chest expansion

• Regular respiratory effort

• No use of accessory muscles

• Clear breath sounds throughout both lungs

• No wheezes, crackles, or rhonchi

There was no clinical evidence of respiratory compromise.

Gastrointestinal Examination

The abdominal examination showed no abnormalities.

Assessment findings included:

• Flat abdomen

• Active bowel sounds in all four quadrants

• Soft abdomen on palpation

• No tenderness

• No hepatomegaly

• No splenomegaly

Overall, gastrointestinal function appeared normal.

Genitourinary Examination

The genitourinary assessment revealed no significant abnormalities.

Findings included:

• Non-distended bladder

• No costovertebral angle (CVA) tenderness

• Normal external genitalia

• Coarse pubic hair in normal distribution

• Skin pigmentation consistent with surrounding tissue

• Bilaterally palpable testes

• No masses

• No hernias

• No urethral discharge

Musculoskeletal Examination

The musculoskeletal examination identified the primary abnormalities associated with the patient’s presenting complaint.

Although the patient demonstrated full range of motion in most extremities while moving around the examination room, significant findings were isolated to the right wrist.

Notable abnormalities included:

• Limited range of motion of the right wrist

• Positive Phalen’s test

• Positive Tinel’s sign

• Decreased pinch strength in the right hand

• Reduced functional grip strength

Despite the patient’s complaint of neck stiffness, cervical spine range of motion remained within normal limits. Deep tendon reflexes were graded 2+ throughout, indicating intact reflex function.

The combination of a positive Phalen’s test, positive Tinel’s sign, and diminished pinch strength strongly suggests compression of the median nerve within the carpal tunnel.

Neurological Examination

A focused neurological examination was performed to evaluate motor and sensory function.

The patient demonstrated:

• Clear and fluent speech

• Normal muscle tone

• Stable posture

• Normal gait

• Intact balance

• Cranial nerves II–XII intact

• Normal sensation to light touch

The primary neurological deficit was weakness affecting the right hand, while no widespread neurological abnormalities were identified.

Psychiatric Assessment

Mental status examination showed appropriate cognitive and emotional functioning.

The patient was:

• Alert and fully oriented

• Appropriately dressed

• Maintaining good eye contact

• Speaking with normal rate, rhythm, and cadence

• Responding appropriately throughout the interview

There was no evidence of anxiety, depression, confusion, or impaired judgment.

Laboratory Findings

Routine laboratory investigations were performed to evaluate the patient’s overall health and identify any metabolic or systemic conditions that might contribute to peripheral neuropathy or delayed healing.

Overall, the laboratory findings did not indicate diabetes mellitus, metabolic abnormalities, or infectious diseases that could explain the patient’s symptoms. The normal hemoglobin A1c level is particularly important because diabetes is a well-recognized risk factor for peripheral neuropathy and carpal tunnel syndrome.

Diagnostic Findings

The objective assessment strongly supports a diagnosis of carpal tunnel syndrome. Several examination findings are considered classic indicators of median nerve compression.

The most significant diagnostic findings include:

• Progressive right-hand weakness

• Limited range of motion in the right wrist

• Positive Phalen’s maneuver

• Positive Tinel’s sign

• Reduced pinch strength

• Occupational history involving repetitive wrist movements as a tailor

• Normal neurological examination outside the affected hand

• Laboratory findings that rule out common systemic causes of neuropathy

Taken together, the patient’s history, physical examination, and laboratory results provide strong clinical evidence supporting carpal tunnel syndrome while making alternative systemic causes less likely.

Assessment

Based on the patient’s history, occupational risk factors, physical examination findings, and laboratory results, the most likely diagnosis is carpal tunnel syndrome (CTS). This condition occurs when the median nerve becomes compressed as it passes through the carpal tunnel in the wrist. The patient’s occupation as a tailor requires repetitive hand and wrist movements, making repetitive strain the most probable contributing factor.

Several clinical findings strongly support this diagnosis, including progressive right-hand weakness, reduced pinch strength, positive Phalen’s test, positive Tinel’s sign, and worsening pain during repetitive hand activities. The absence of systemic disease, trauma, or metabolic abnormalities further strengthens the diagnosis.

Differential Diagnoses

Although carpal tunnel syndrome is the leading diagnosis, several other conditions should be considered before confirming the final diagnosis.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel. Repetitive wrist flexion and extension can increase pressure inside the tunnel, reducing blood flow to the nerve and causing inflammation. Over time, persistent compression may result in nerve damage, weakness, numbness, and decreased hand function.

Clinical findings supporting this diagnosis include:

• Positive Phalen’s test

• Positive Tinel’s sign

• Progressive right-hand weakness

• Reduced pinch strength

• Pain aggravated by repetitive hand use

• Occupational exposure to repetitive wrist movements

Osteoarthritis of the Wrist

Osteoarthritis is another possible cause of chronic wrist pain, particularly in older adults. Degenerative changes within the wrist joints may lead to stiffness, discomfort, and reduced mobility.

However, several findings make osteoarthritis less likely in this patient:

• No visible joint deformity

• No joint swelling

• No crepitus

• Positive nerve compression tests favor CTS rather than joint degeneration

Wrist Sprain or Ligament Overuse Injury

A repetitive strain injury or chronic ligament sprain may also produce wrist pain and decreased grip strength.

This diagnosis is considered less likely because:

• The patient reported no recent trauma.

• Symptoms developed gradually over three months.

• Positive Phalen’s and Tinel’s tests indicate nerve involvement rather than ligament injury.

• Physical examination did not reveal instability or swelling consistent with a ligament sprain.

Final Diagnosis

Carpal Tunnel Syndrome

The patient’s presentation is most consistent with carpal tunnel syndrome, a compressive neuropathy involving the median nerve.

The median nerve passes through a narrow anatomical passage called the carpal tunnel, along with several flexor tendons. Swelling of the surrounding tissues or repetitive mechanical stress can increase pressure within the tunnel, compressing the nerve. As pressure increases, blood flow to the nerve decreases, leading to inflammation, pain, numbness, weakness, and impaired hand function.

Without timely intervention, prolonged compression may result in permanent nerve damage and muscle weakness, particularly affecting the muscles at the base of the thumb.

Because Mr. Sinclair performs repetitive sewing activities daily, his occupational exposure is the most significant contributing factor to the development of his condition.

Evidence-Based Treatment Plan

Management should focus on reducing median nerve compression, relieving pain, improving hand function, and preventing long-term nerve damage.

Pharmacological Management

Initial treatment includes conservative pain management using anti-inflammatory medication.

Recommended medications include:

• Naproxen 220 mg orally once daily to reduce pain and inflammation.

• If naproxen cannot be tolerated because of gastrointestinal side effects, consider corticosteroid therapy after further clinical evaluation.

Because the patient previously experienced stomach discomfort with ibuprofen, careful monitoring for gastrointestinal adverse effects is recommended while taking nonsteroidal anti-inflammatory drugs (NSAIDs).

Non-Pharmacological Management

Conservative therapy remains the first-line treatment for mild to moderate carpal tunnel syndrome.

Recommended interventions include:

• Rest the affected hand whenever possible.

• Apply ice to reduce inflammation.

• Use compression if appropriate.

• Elevate the wrist to minimize swelling.

• Wear a neutral-position wrist splint, especially during nighttime.

• Reduce repetitive wrist movements at work.

• Modify workstation ergonomics to decrease stress on the wrist.

These interventions can significantly reduce symptoms and slow disease progression.

Recommended Diagnostic Testing

Although the clinical examination strongly supports carpal tunnel syndrome, additional diagnostic testing may help confirm the diagnosis and exclude other conditions.

Recommended investigations include:

• Wrist X-ray to exclude fractures, arthritis, or structural abnormalities.

• Musculoskeletal ultrasound to evaluate median nerve compression and tendon abnormalities.

If symptoms persist or worsen, nerve conduction studies (NCS) and electromyography (EMG) should also be considered, as these tests are regarded as the gold standard for confirming median nerve dysfunction.

Patient Education

Patient education is an essential component of successful treatment and long-term symptom management.

Mr. Sinclair should receive education regarding:

Medication Safety

Patients taking NSAIDs should understand the potential risks of gastrointestinal irritation.

He should be instructed to:

• Take naproxen with meals.

• Avoid taking multiple NSAIDs simultaneously.

• Report symptoms such as:

  • Black stools

  • Vomiting blood

  • Persistent stomach pain

  • Severe heartburn

  • Unusual bruising or bleeding

Wrist Splint Use

Proper splint use can significantly reduce pressure on the median nerve.

The patient should:

• Wear the splint during sleep.

• Use it during repetitive activities if symptoms increase.

• Avoid tightening the splint excessively.

• Continue gentle finger movements while wearing the splint.

Activity Modification

To reduce symptom progression, the patient should:

• Take frequent breaks during sewing.

• Perform stretching exercises for the wrist and fingers.

• Maintain proper wrist posture.

• Avoid prolonged gripping or repetitive forceful hand movements.

Cultural Considerations

Healthcare providers should deliver culturally sensitive care that respects the patient’s beliefs, preferences, and health literacy.

For Mr. Sinclair, important considerations include:

• Discussing treatment options using clear, understandable language.

• Encouraging shared decision-making.

• Considering cardiovascular risk factors before prolonged NSAID therapy.

• Respecting cultural beliefs that may influence treatment adherence.

Health Promotion and Preventive Care

Although the patient’s current concern involves carpal tunnel syndrome, age-appropriate preventive care remains essential.

Recommended preventive screenings include:

• Colorectal cancer screening

• Routine prostate examination

• Blood pressure screening

• Type 2 diabetes screening

• Annual wellness examinations

• Routine lipid monitoring

These preventive measures support healthy aging and facilitate the early detection of chronic diseases.

Referrals

Interprofessional collaboration can improve treatment outcomes.

Recommended referrals include:

• Physical Therapy (PT): To improve wrist strength, flexibility, ergonomics, and functional recovery.

• Orthopedic Specialist (Orthopedics): For further evaluation if symptoms persist despite conservative management or if surgical intervention becomes necessary.

Follow-Up

The patient should return for follow-up as needed or sooner if symptoms worsen.

Follow-up visits should assess:

• Pain severity

• Grip strength

• Functional improvement

• Medication tolerance

• Compliance with wrist splint use

• Need for advanced imaging or specialist referral

If conservative treatment fails after several weeks, referral for nerve conduction studies and consideration of surgical decompression may be appropriate.

Key Clinical Takeaways

This case highlights several important clinical considerations for the assessment and management of carpal tunnel syndrome.

• Progressive hand weakness and reduced grip strength are hallmark symptoms of median nerve compression.

• Positive Phalen’s and Tinel’s tests are valuable bedside assessment tools for diagnosing carpal tunnel syndrome.

• Repetitive occupational hand movements significantly increase the risk of developing carpal tunnel syndrome.

• Conservative management, including wrist splinting, activity modification, NSAIDs, and physical therapy, is effective for many patients with mild to moderate disease.

• Early diagnosis and intervention can prevent permanent nerve damage and improve long-term functional outcomes.

References 

Branch, N. S. C. a. O. (2025, June 6). Carpal tunnel syndrome. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/carpal-tunnel-syndrome

American Academy of Orthopaedic Surgeons. (n.d.). Carpal tunnel syndrome. OrthoInfo. https://orthoinfo.aaos.org/en/diseases–conditions/carpal-tunnel-syndrome/

National Institute of Diabetes and Digestive and Kidney Diseases. (2025, February 18). Prostate tests. https://www.niddk.nih.gov/health-information/diagnostic-tests/prostate

NU566 Unit 7 Journal

U.S. Preventive Services Task Force. (2021, May 18). Colorectal cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

U.S. Preventive Services Task Force. (2021, April 27). Hypertension in adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening

U.S. Preventive Services Task Force. (2021, August 24). Prediabetes and type 2 diabetes: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes