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Wrist Pain In A Confused Farmer - Page #1
 

Author: Justin Chu, MD
Co Author #1: Justin Chu, MD
Senior Editor: Siobhan Statuta, MD, FAMSSM
Editor: Heather Rainey, MD

Patient Presentation:
A 79 year old male with acute encephalopathy presented to this primary care doctor's office with right wrist pain.

History:
He had a past medical history of hypertension, chronic obstructive pulmonary disease, and dementia. He lived and worked alone on a 40 acre farm in Kentucky and was a former smoker. At the office, there was concern about his level of confusion, speech, and upper extremity weakness. He was sent to the nearest emergency department where a computed tomography head and computed tomography angiography head/neck ruled out an acute stroke. He was subsequently admitted for encephalopathy workup and wrist pain.

Physical Exam:
Vital signs:
Temperature 98.1F
Blood pressure 150/80
Heart rate 93
Respiratory rate 20
Body mass index 36.3kg/m2

On neurological exam, he was confused and only oriented to person. Cranial nerves II-XII were grossly intact. No neglect or gaze deviation was noted. His face was symmetric, and he was edentulous.

Right upper extremity exam showed wrist and hand without any lacerations or abrasions. There was significant erythema and swelling over the wrist and into mid-dorsal aspect of hand. He was extremely painful to palpation (even gentle brushing) and with any movement of wrist, hand, or fingers. He had decreased sensation throughout his hand. Radial pulse was palpable and capillary refill was less than 3 seconds.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.

NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.
 

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