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Identifying DataA case of Lorna B. Ulbata, 56 years old, female, single,
Filipino, Roman Catholic, presently residing at Brgy.Cancayang, Javier Leyte, admitted for the 1st time atRTRH.
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RightHand
Swelling
Chief
Complaint
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History of Present Illness Patient accidentally slide and her
right hand first touch the ground
which supported the whole body (+) swelling of the hand
(+) pain with pain scale of 7 outof 10
Went to manghihilot for 9sessions with increase of swellingnoted and was prescribed withCefalexin BID x 15 days
2months
PTA
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History of Present Illness
Still with swelling of the right hand &burning pain sensation radiating to theforearm and to the elbow
Consultation done at Abuyog DistrictHospital
Right hand x-ray was done
Impression: complete fracture of the
right distal radial bone with callusformation
3weeks
PTA
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History of Present Illness
With restrictions in the shoulder
movements (especially abduction) noted Impossible to make a fist
Consultation done to a private physician
Medications:
Alenpronale (Revanta)
Celecoxib 200mg 1 capsule Calcium+Vitamin D (Calci Pluc) 1 tab
Less relief of pain & swelling noted
1Week
PTA
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Past Medical History Past Hospitalization:
2009: gastric ulcer at Abuyog District Hospital
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Psychosocial History Patient is a self-employed
Commerce Graduate
A non-smoker Non-alcoholic beverage drinker
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Review of System General: No weight Loss, no body Malaise Skin: shiny, swelling right hand Head: no headache, no lightheadedness, no dizziness
Eyes: no pain, no redness Ears: no earache, no discharges Nose & Sinuses: no congestion, no nasal stuffiness Mouth & Throat: no sorethroat, no bleeding gums Neck: no pain, no rigidity
Respiratory: no dyspnea, no hemoptysis, no orthopnea Cardiovascular: no chest pain, no palpitatons GIT: good appetite, no nausea, no vomiting GUT: no hematuria, no polyuria, no dysuria, no oliguria Musculoskeletal: with muscle & joint pain at the right hand
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Physical Examination Patient was conscious, coherent, oriented to time,
place & person, afebrile, mesomorph, well developed,well nourished, not in cardiorespiratory distress withthe following vital signs:
BP- 140/90 mmHg
HR 112 bpm
RR 24 cpm Temperature 36.4
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Physical Examination Skin:
Inspection: brown complexion, with swelling & shiny
on the right right hand Palpation:warm, hyperhidrosis, with good skin turgor
Nails: pinkish nail beds with good capillary refill (
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Head:skull is normocephalic, black long hair equally distributed,temples not depressed, no nits, no scalp lesionno tenderness
Eyes:Eyebrows: symmetric, black hair, no lesions, no scarsEyelashes: fine black hair, ectropionEyelids: no lidlag, no ptosis, no edema, no swelling, no scarsConjunctiva: pinkish palpebral conjunctiva, no hemorrhages,no active lesions, no ulcerationsSclera: anicteric, no hemorrhage, no active lesionsCornea, Iris, Lens: with opacity, no active lesions, nolacerations or serrations
Pupils: round, asymmetrical, 2-3mm in diameter from normal
to constriction, briskly reactive to direct and consensual lightstimulation
EOM: full
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Ears: symmetrical, no impacted cerumen, no discharges, hearing notimpaired,no tenderness
Nose and Sinuses: pinkish mucous membrane, septum at midline, nodischarges, no congestion, no nasal flaring, no sinus tenderness
Mouth and Throat:
Lips: symmetrical, pinkish in color, no lesions, no cheilosis, and noangular deviation
Buccal mucosa: pale, moist mucous membrane, no lesions
Teeth: complete set of teeth, no false dentures
Gingiva: no swollen gums, uvula at midline
Tonsils: no enlargement, no redness, no abscess
Neck:supple, trachea at midlineBreast: symmetrical, no lesions, no discharges, no lumps, no palpable
lymph nodes, no tenderness
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Chest and Lungs:
Inspection: symmetrical lung expansion, no lagging, nosubscapular and intercostal retraction on respiration
Palpation: confirmed symmetrical chest expansion, unimpairedtactile fremitus, no masses, no tenderness
Percussion: resonant in all lung fields
Auscultation: no crackles, no wheezes, no pleural friction rub
Cardiovascular:
Inspection: adynamic precordium, no precordial bulging, novisible pulsation, PMI at 5th ICS left midclavicular line
Palpation: PMI noted at 5th ICS left midclavicular line, no
heaves, no thrills, no tenderness Auscultation: regular rhythm and synchronous with pulse rate,
no murmurs, no pericardial friction rub
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Abdomen:
Inspection: globular, no visible peristalsis, no engorged vein,no hypo/hyperpigmentation
Palpation: no tenderness, no mass, liver not enlarged,kidney not palpable
Percussion: tympanitic all over
Auscultation: normoactive bowel sounds, no arterial bruit,no venous hum, no peritoneal friction rub
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Extremities:Range ofMotionShoulder
PE RightShoulder
PE LeftShoulder
PE RightShoulder
PE LeftShoulder
Flexion 80 degrees 180 degrees 4/5 5/5
Extension 15 degrees 80 degrees 4/5 5/5Abduction 90 degrees 3/5 5/5
Adduction 60 degrees 90 degrees 4/5 5/5
Internal
Rotation
10 degrees 55 3/5 5/5
ExternalRotation
10 degrees 45 degrees 4/5 5/5
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Extremities:ROM of theElbow
Right elbow Left Elbow Right elbow Left Elbow
Flexion 150 degrees 150 degrees 4/5 5/5
Extension - 10 degress 10 degrees 4/5 5/5
Supination 5 degrees 80 degrees 3/5 5/5
Pronation 70 degrees 80 degrees 4/5 5/5
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Extremities:ROM of theWrist
Right Wrist Left Wrist Right Wrist Left Wrist
Flexion 20 degrees 80 degrees 3/5 5/5
Extension 20 degrees 70 degrees 3/5 5/5
Adduction(Radialdeviation )
5 degrees 20 degrees 3/5 5/5
Abduction(UlnarDeviation)
5 degrees 30 degrees 3/5 5/5
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Extremities:ROM of the fingers &Thumb
Right Left
First interphalangealflexion
10 degrees 80 degrees
Second, third, and fourthinterphalangeal flexion
10 degrees 100 degrees
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SensorySensationTesting
Light touch Pinprick
C5 Lateral side of theantecubital fossa
+++ +++
C6 Thumb +++ +++
C7 Middle Finger +++ +++
C8 Little finger +++ +++
T1 Medial side of the
antecubital fossa
+++ +++
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ReflexesBiceps Triceps Brachialis Knee AnkleRight 1+ 1+ 1+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
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Neurologic Exam:
MENTAL STATUS EXAM: alert, coherent and oriented to person, place, andtime, no mental changes and confusion noted.
CRANIAL NERVES:
CN I: no anosmia
CN II & III: pupils 2-3 mm in diameter, symmetrical, equally reactive to
direct and consensual light stimulation CN III, IV, VI: able to move eyes upward, downward, medially and laterally
CN V: intact sensory function to pain and touch, with intact corneal reflex
CN VII: able to smile, able to frown
CN VIII: responsive to verbal stimuli
CN IX and X: with intact gag reflex, able to swallow
CN XI: able to turn head to both sides against resistance, able to shrugshoulder
CN XII: able to protrude tongue, no deviation to L/R
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Course in the WardsAdmission
1stst HOSPITAL DAY
Motor: increase of the ROM of the shoulder Less swelling
2nd HOSPITAL DAY
Motor: increase of the ROM of the shoulder
No swelling
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Diagnostics Procedure
Results
Hemoglobin 150Hematocrit 0.42
WBC 7.85
Neutrophils 0.72
Lymphocytes 0.27
Monocytes 0.01
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Salient Features1. 56 years old2. Female3. Single4. Swelling of the right hand5. Injury of the right hand for about 2 months ago6. Continuous Burning Pain radiating to the forearm & elbow7. Decreased ROM of the right shoulder, elbow, wrist, fingers &
thumb Restriction of right shoulder movement With restrictions in the shoulder movements (especially
abduction) noted Impossible to make a fist
8. Hyperesthesia, allodynia, hyperhidrosis
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NERVE ENTRAPMENT/
COMPRESSION SYNDROMESRule In Rule Out
1. Swelling of the right hand
2. Injury of the right hand for about2 months ago
3. Continuous Burning Pain
1. Continuous Burning Pain
radiating to the forearm & elbow2. Decreased ROM of the right
shoulder, elbow, wrist, fingers &thumb Restriction of right shoulder
movement
With restrictions in theshoulder movements(especially abduction) noted
Impossible to make a fist
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FibromyalagiaRule In Rule out56 years oldFemale regional areas of pain
11/18 tender pointRelated to sleep, problems anxiety ordepression
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Posttraumatic neuralgiaRule In Rule Out1. Injury of the right hand for about
2 months ago2. Decreased ROM of the right
shoulder, elbow, wrist, fingers &thumb
3. Continuous Burning Pain4. Weakness of the right hand
1. Swelling of the right hand2. progressive spread of symptoms.3. obtain relief with sympatholytic
procedures
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COMPLEX REGIONAL PAIN
SYNDROME (CRPS)RULE IN RULE OUT
1. 56 years old2. Female3. Single
4. Swelling of the right hand5. Injury of the right hand for about 2 months ago6. Continuous Burning Pain radiating to the forearm & elbow7. Decreased ROM of the right shoulder, elbow, wrist, fingers
& thumb Restriction of right shoulder movement With restrictions in the shoulder movements
(especially abduction) noted Impossible to make a fist
8. Hyperesthesia, allodynia, hyperhidrosis
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ANATOMY & PHYSIOLOGY
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Brachial Plexus
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CRPS is a neuropathic pain syndrome characterized by
autonomic dysfunction and severe pain that may leadto crippling contractures of the limbs.
A variety of painful conditions following injury whichappears regionally having a distal predominance ofabnormal findings exceeding in both magnitude andduration the expected clinical course of the incitingevent, often resulting in significant impairment ofmotor function and showing variable progression overtime
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CRPS COMPLEX varied and dynamic clinical presentation
REGIONAL non-dermatomal distribution of thesymptoms
PAIN out of proportion to the inciting events
SYNDROME constellation of symptoms and signs
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International Association for the
Study of Pain (IASP) Nomenclature CRPS I = reflex sympathetic dystrophy
CRPS II = causalgia
A.K.A = algodystrophy, shoulder-hand syndrome,Sudeck's atrophy, transient osteoporosis and acute
atrophy of bone
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CRPS Female to male ratio: 3:1
Any age, but middle age predominates (median 42years old)
Onset 9-85 years old
CRPS occurs in about 1-2% of patient who have hadfractures and in approximately 2-5 % of patients after
peripheral nerve injuries
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Clinical Manifestation1. Pain
Continuous , constant, burning, aching, throbbing
Disproportionate to the injury
Asymmetrical and not in distributuion of a peripheralnerve, worst in distal
2. Autonomic abnormalities
Vascular: hot swollen erythematous/cold, blached &mottled
Sudomotor: Hyperhydrosis
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Clinical Manifestation1. Motor
Diffuse weakness of the extremity
2. Trophic changes
Nail growth
Loss of function: muscle, joints & tendon
Hair changes (coarse/loss of hair)
Skin-thin and glossy, loss of elasticity osteoporosis
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CRPS I1. The presence of an initiating noxious event or acause of immobilization
2. Continuing pain, allodynia or hyperalgesia with
which the pain is disproportionate to the incitingevent.
3. Evidence of some time of edema, changes in skinblood f low or abnormal sudomotor activity in the
region of pain4. The diagnosis is excluded by the existence of
conditions that would otherwise account for thedegree of pain & dysfunction
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CRPS II (Causalgia) Criteria1. The presence of continuous pain, allodynia or
hyperalgesia after a nerve injury, not necessarilylimited to the distribution of the injured nerve
2. Evidence of some time of edema, changes in skinblood f low or abnormal sudomotor activity in theregion of pain
3. The diagnosis is excluded by the existence ofconditions that would otherwise account for thedegree of pain & dysfunction
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PathophysiologyUnknown
3 main hypotheses
Facilitated neurogenic inflammation
Autonomic dysfunction
Neuroplastic changes within the CNS
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Treatment Goals Relief of pain
Return of function
Prevent or slow the progression
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Treatment1. Physical Therapy2. Pain
Eterocoxib 120 mg 1 tab OD
NSAIDs
3. Steroids
4. Gabapentin & Pregabalin
5. Calcitonin
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Sympathetic Blockade Lumbar sympathetic block
Stellate ganglion block
IV regional anesthesia block
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