For Professionals

Drug Seeking Behaviour

Altering the route of delivery

  • Injecting oral formulations
  • Crushing Oral formulations

Accessing opioids from other sources

  • Taking drugs from family or friends
  • Buying prescription medications from the street
  • Multiple-doctoring

Drug seeking

  • Recurrent prescription losses
  • Ongoing complaints about need to increase dose
  • Asking for specific medication


Presenting with withdrawal symptoms

  • Dysphoria
  • Myalgias
  • Diarrhea
  • Cravings
  • Sweating
  • Goosebumps

Concurrent disorders

  • Alcohol dependence
  • Stimulant abuse
  • Cannabinoids abuse
  • Mood disorders resistant to treatment
  • Anxiety disorders resistant to treatment

Social instability

  • Family and relationship problems
  • Job loss and unemployment
  • Concerns expressed by family or friends


Personal believes

  • Resistance to dose reduction
  • Reporting severe withdrawal symptoms with minor dose reduction
  • Denying dependence



Spirometry is one of the best and most commonly used lung function tests. The test is done with a device called a spirometer. The spirometer is an instrument that measures lung capacity which is a reflection of lung function. This instrument displays readings which will be recorded as a part of SHOW data collection.

Spirometry includes but is not limited to the measurement of forced vital capacity (FVC), the forced expiratory  volume in the first second (FEV1), and other forced expiratory flow measurements such  as the FEF25-­75%. In addition, it sometimes includes the measurement of maximum  voluntary ventilation (MVV). A graphic representation (spirogram) of the maneuver  should be a part of the results. Either a volume­time or flow­volume display is acceptable. Other parameters that may be obtained by spirometry include FEFmax (PEF), FEF75%, FEF50%, FEF25%, FIF50%, and FIFmax (PIF).


  • to show the presence or absence of lung dysfunctions
  • to assess severity of known lung disease
  • to assess change of lung function in function of time or in function of therapy
  • to assess the potential effect of occupational or environmental exposure
  • to assess the potential risk for surgical interventions that can effect lung function
  • to assess disability


  • Hemoptysis of unknown cause
  • Pneumothorax
  • Unstable cardiovascular status
  • Recent myocardial infarctation
  • Recent pulmonary embolism
  • Thoracic, abdominal or cerebral aneurism (risk of rupture because the increased intrathoracic pressure during forced expiration)
  • Recent ocular surgery (eg. cataract)
  • Nausea, vomiting
  • Recent thoracic or abdominal surgery
  • Eye, ear, oral, brain, or cardiothoracic surgeries in the last 3 months

Hazards of spirometry

Although spirometry is a safe procedure, untoward reactions may occur, and the value of the information anticipated from spirometry should be weighed against potential hazards.  The following have been reported anecdotally:

  1. Pneumothorax;
  2. Increased intracranial pressure;
  3. Syncope, dizziness, light­headedness;
  4. Chest pain;
  5. Paroxysmal coughing;
  6. Contraction of nosocomial infections;
  7. Oxygen desaturation due to interruption of oxygen therapy;
  8. Bronchospasm


  1. Spirometry in primary care.
  2. UMHS Indications for Spirometry in Primary Care Clinics.
  3. . Enright PL, Johnson LR, Connett JE, Voelker H, Buist AS. Spirometry in the lung  health study: 1. Methods and quality control. Am Rev Respir Dis 1991;143(6):  1215­1223.

Lower Back Pain


There are two types of low back pain

  1. Acute: lower back pain for less than 3 months
  2. Chronic: lower back pain that has been present for more than 3 months

Differential diagnosis


    • Steroid use > 3 months
    • Hypertension medications?


    • Osteomyelitis
    • Spinal TB
    • Urinary tract infection (sign of urinary retention)
    • Reiters disease if patient is a young guy with symptoms of STI
    • Inflammatory (seroneg/spondyloarthropathies)
    • Ankylosing Spondylitis
      • If young (20-30), no radiation, and pain is worst at movement and better with rest
    • Morning stiffness relieved by activity.
      • Joint pain,
      • Uveitis (inflammation of the uveal tract: iris, ciliary body, and choroids)


    • Osteoporotic
    • Osteomalacia
    • Paget’s


    • Spondylolisthesis: Forward displacement of a lumbar vertebra
    • Disc herniation:
      • Sciatica:
        • Pain due to entrapment of sciatic nerve
        • Patient complains of pain, burning or aching in buttocks radiating down posterior thigh to the posterolateral aspect of calf
        • Pain worse with sneezing, laughing or straining during bowel movement
      • Cauda equina syndrome:
        • Leg weakness
        • Lax anus
        • Impotence,
        • Urinary retention
        • Fecal incontinence
        • Is surgical emergency
    • Spinal stenosis:
      • is characterized by worsening of symptoms with standing and walking, with relief on bending and setting (a typical history of leaning on and bending over the shopping cart for relief of pain while shopping is suggestive of spinal stenosis).
      • Nerve root entrapment in lumbar spinal stenosis is caused by narrowing of the spinal canal (congenital or acquired), nerve root canals, or intervertebral foramina
      • This narrowing is usually caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum. Disc bulging and spondylolisthesis may contribute.
      • Symptoms of significant lumbar spinal stenosis include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest.
      • This pain with walking, referred to as “pseudoclaudication” or “neurogenic claudication”, is clinically distinguished from vascular claudication by the presence of normal arterial pulses
    • Pancreatitis
    • Aortic aneurysm
    • PUD
    • Kidney stone
    • Pyelonephritis
    • Prostatitis
    • Endometriosis
    • PID


  • Pain lower back with or without radiation to thighs or legs
  • Fever may be present in case of infection
  • Limping

History taking


  • Location (worse in leg or back? Radiates to shoulder?)
  • Onset
  • Duration
  • Type of pain: Deep dull pain, sharp pain,
  • Severity
  • Triggering event
  • Pattern, changes with position
  • Progression
  • Alleviating: rest, warmth
  • Aggravating Factors: lifting, walking, sitting, bending

Associated symptoms:

  • Previous illness
  • Past trauma
  • Constitutional (fever, fatigue, night sweats, wt loss, chills)
  • Eye syndromes
  • Heart diseases
  • GU (retention, frequency, overflow incontinence, hesitancy, erectile)
  • Bowel (incontinence, perianal sensory loss)
  • Other neuro: Saddle anesthesia, loss of sensation, weakness in arms / legs


  • Ask about emotional consequences of the injury, the goals of treatment and the visit, patients concerns
  • Occupational impact
  • Limitation in usual activities
  • Social / recreation / sleep
  • How long can pt sit / stand / walk
  • How much weight can lift

Past Medical History

  • Previous hx of back pain / treatment / surgery
  • Recent infection (UTI)
  • Hospitalizations for back injuries
  • HIV
  • IVDU
  • Corticosteroid use
  • Vascular disease
  • Autoimmune disease
  • Supplement use (no use vs. too much use)
  • Depression or other mental conditions
  • Past history of trauma or injuries
  • Previous history of cancer

Physical exam

Vital Signs:

  • Temperature
  • BP
  • PR
  • Weight (loss)

Inspection (cervical, thoracic, lumbar)

  • Appearance, distress, sitting or standing position
  • Posture
  • Asymmetry
  • Skin rash or redness on back or hips
  • Deformity (lordosis or loss of lordosis, kyphosis, scoliosis, rib hump)
  • Signs of inflammation, trauma, scars
  • Gluteal muscle atrophy
  • LN exams
  • Uveitis
  • Abdominal pain or tenderness
  • Balonitis


  • Abnormal gait


  • Tenderness (spinous processes & paravertebral muscles)
  • Prominence & Alignment spinous processes
  • Palpate SI joints
  • Spasm of muscles


  • Spinous processes
  • Costovertebral Angle

Range of Motion

  • Forward bending (lumbar disc herniation)
  • Extension (facet joint or spinal stenosis)
  • Lateral flexion
  • Rotation (T12 – L1)
  • Chest expansion

Trendelenbreg test

Neurological Screen

  • Motor
  • Ask client to Squat (L4)
  • Ask client to Heel walk (L5)
  • Ask client to Walk on toes (S1-2)
  • Sensory
    • Medial calf (L4)
    • 1st web space (L5)
    • Lateral foot (S1)
  • Reflex
    • Knee jerk (L4)
    • Ankle jerk (L5)
    • Babinski
  • Straight leg raise:
    • The test is positive if significant back pain, or radicular pain in the lower extremity is present.
    • A positive test may indicate sciatic or lumbosacral nerve root irritation, for example due to a prolapsed lumbar disc.
    • Dorsiflex the foot at 45 degree is pain it is indicative of sciatica pain.
    • If the leg pain increases but without spinal symptoms consider piriformis syndrome.
    • If positive watch for quada equine syndrome.
  • Femoral stretch test (L2,3,4)
  • SI joint (flex hip & knee, hyperextend opposite), sacral compression pain
  • Peripheral Vascular system
    • Inspect for venous stasis or arterial insufficiency ulcers, check femoral pulses and auscultate for femoral bruits, feel popliteal, dorsalis pedis and tibialis posterior pulses.
  • Rectal exam:
    • Tone
    • Hemorrhoid

Social History

  • Lifestyle
  • Hobbies
  • Physical activity
  • Diet and nutrition
  • Drug and alcohol use
  • Employment history
  • High risk sexual disorders

Laboratory work up

  • ESR if is febrile or if cancer is in DDx
  • Alk Phosphatase
  • PSA if suspect prostate cancer

Diagnostic tests

  • Lubosacral X-Ray
  • CT-Scan: is the test of choice to investigate pain suspected to be from multi-segmental bony stenosis and fracture
  • MRI: is the primary diagnostic tool when cauda equine or malignancy is suspected or if there is past history of cancer or history of progressive worsening radiculopathy over 4 months


  • Yoga maybe beneficial
  • Spinal traction not helpful
  • Physical therapy
  • Chiropracter manipulation may be helpful in patients with simple back pain but not on those with radiculopathy
  • Start NSAIDS if no contraindications
  • Opioids are no better than non-opioids
  • Surgery consult if:
  • Quada equine syndrome
  • Persistent sciatica
  • Sensory deficit
  • Positive straight leg raise

Mental Status Exam


Affect is described by labelling the apparent emotion conveyed by the person’s nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility.

Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia.

The intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic.

A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders.

Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile.

The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect.

The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive.



  • Citalopram (Celexa)
    • Available doses: 10 mg, 20 mg, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 40 mg
  • Escitalopram (Cipralex; Lexapro):
    • Available doses: 5 mg, 10 mg, 20 mg
    • Starting dose: 10 mg
    • Usual dose: 10 to 20 mg
  • Fluoxetine (Prozac):
    • Available doses: 10 mg, 20 mg, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 60 mg
  • Fluvoxamine (Luvox):
    • Available doses: 25 mg, 50 mg, 100 mg
    • Starting dose: 50 mg
    • Usual dose: 50 to 300 mg
  •  Paroxetine (Paxil):
    • Available doses: 10 mg, 20 mg, 30 m g, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 40 mg
  •  Paroxetine CR
    • Available doses: 12.5 mg, 25 mg, 37.5 mg
    • Starting dose: 25 mg
    • Usual dose: 25 to 62.5 mg
  • Sertraline (Zoloft:
      • Available doses: 25 mg, 50 m g, 100 mg
      • Starting dose: 50 mg
      • Usual dose: 20 to 200 mg


  • Duloxetine (Cymbalta)
    • Available doses: 20 mg, 30 mg, 60 mg
    • Starting dose: 30 mg
    • Usual daily dose: 60 to 90 mg
  • Venlafaine (Effexor):
    • Available doses: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg
    • Starting dose: 37.5 mg
    • Usual daily dose: 75 to 225 mg
  • Venlafaine XR (Effexor XR):
    • Available doses: 37.5 mg, 75 mg, 150 mg
    • Starting dose: 37.5 mg
    • Usual daily dose: 75 to 225 mg

Serotonin Modulators

  • Nefazodone (Serzone):
    • Available doses: 100 mg, 150 mg, 200 mg, 250 mg
    • Starting dose: 50 mg
    • Usual daily dose: 150 to 300 mg
  • Trazodone (Desyrel):
    • Available doses: 50 mg, 100 mg, 150 mg, 300 mg
    • Starting dose: 50 mg
    • Usual daily dose: 75 to 300 mg

Norepinephrine-Serotonin Modulators

  • Mirtazapine (remeron):
    • Available doses: 7.5 mg, 15 mg, 30 mg, 45 mg
    • Starting dose: 15 mg
    • Usual daily dose: 15 to 45 mg


Tertiary amine tricyclics

  • Amitriptyline (Elavil):
    • Available doses: 10 mg, 25 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 mg to 300 mg
  • Clomipramine (Anafranil):
    • Available doses:25 mg, 50 mg, 75 mg
    • Starting dose: 25 mg
    • Usual daily dose: 100 to 250 mg
  • Doxepin (Sinequan):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Imipramine (Tofranil):
    • Available doses: 10 mg, 25 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Trimpiramine (Surmontil):
    • Available doses: 25 mg, 50 mg, 100 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg

Tertiary amine tricyclics

  • Desipramine (Normpramine):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Nortiptyline (Pamelor, Aventyl):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg
    • Starting dose: 25 mg
    • Usual daily dose: 50 to 150 mg
  • Protriptyline (vivactil):
    • Available doses: 5 mg, 10 mg
    • Starting dose: 10 mg
    • Usual daily dose: 15 to 60 mg


  • Amoxapine (Asendin):
    • Available doses: 25 mg, 50 mg, 100 mg, 150 mg
    • Starting dose: 50 mg
    • Usual daily dose: 100 to 400 mg
  • Maprotiline (Ludiomil):
    • Available doses: 25 mg, 50 mg, 75 mg
    • Starting dose: 50 mg
    • Usual daily dose: 100 to 225 mg


  • Isocarboxzid (Marplan):
    • Available doses: 20 mg, 60 mg
    • Starting dose: 10 mg
    • Usual daily dose: 20 to 60 mg
  • Phenelzine (Nardil):
    • Available doses: 15 mg
    • Starting dose: 15 mg
    • Usual daily dose: 15 to 90 mg
  • Tranylcypromine (Parnate):
    • Available doses: 10 mg
    • Starting dose: 10 mg
    • Usual daily dose: 30 to 60 mg
  • Moclobemide
    • Available doses:100 mg, 150 mg
    • Starting dose: 150 mg
    • Usual daily dose: 300 to 600 mg

Guidelines for choosing antidepressant medications

Unipolar depression:

  • Choose on the basis of previous response, side effects and comorbid medical and psychotic conditions

Bipolar depression:

  • Lithium
  • Lamotrigine
  • Olanzapine-fluoxetine combination

Depression with psychotic features:

  • Antidepressants + Antipsychotics, or
  • ECT
  • Note: Avoid bupropion

Depression and panic disorder:

  • SSRI
  • TCA

Depression and seizure:

  • Note: Avoid Bupropion
  • Note: Avoid TCAs

Depression and Parkinson’s disease:

  • Bupropion

Depression and sexual dysfunction:

  • Bupropion
  • Mirtazapine

Depression and melancholic features:

  • TCA

Depression and atypical features: 

  • SSRIs
  • MAOi



  • Indications:
    • Major depression (15 mg/hs up to 45 mg)
    • Insomnia (15 mg/hs up to 45 mg)
    • Anxiety (15 mg/hs up to 45 mg)
  •  Side effects:
    • Weight gain
    • Sedation at initiation
    • Dizziness
    • Somnolence
    • Orthostatic hypotension
    • Hypertension
    • Peripheral edema due to peripheral vasodilation
  • Drug Interaction:
    • MAOIs
  • Overdose and toxicity:
    • Signs: Drowsiness, impaired memory, tachycardia
    • Treatment: Cardiac monitoring, gastric lavage, supportive measures


  • Indications:
    • Major Depression
    • Insomnia (50 to 100 mg/hs)
  • Side effects:
    • Orthostatic hypotension
    • Arrhythmia
    • Dry mouth
    • Blurred vision
    • Priapism


  • Major depression (start at 37.5 to 75 mg/day to 225 mg/day up to 375 mg/day)
  • Anxiety
  • Chronic pain


  • Major depression (60 mg/day)
  • Pain related to diabetic neuropathy (up to 120 mg/day)
  • Fibromyalgia (120 mg/day)

Bupropion (Wellbutrin; Zyban)

  • Parkinson’s disease
  • Smoking cessation (150 mg SR bid or 300 mg XL once daily)
  • Gradual dose titration reduces initial anxiety and insomnia
  • Avoid in patients with seizure disorders and history of sever head trauma or brain tumor

Side effects


  • Sedation
  • Anticholinergic effects
    • Dry mouth, constipation, urinary retention, blurred vision, tachycardia, dilated pupils, delirium
    • Use with caution in prostatic hypertrophy, narrow-angle glaucoma or cognitive impairment
    • Reduce dose or switch to another category of antidepressants
  • Orthostasis
  • Quinidine like effects on cardiac conduction
  • Sedation
  • Arrhythmia
  • PR Prolongation
  • QRS prolongation
  • Should not be used in patient with heart block
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction
  • Overdose:
    • Seizure, arrhythmia, hypotension, delirium, agitation, hallucination, seizure, HTN, dry mucous membranes, absent bowel sounds, tachycardia
    • Treatment: Atropine, cardiac monitoring, supportive care


  • Minimal Sedation
  • Nausea
  • Loose bowel movements
  • Headache
  • Insomnia
  • Weight gain is rare
  • Sexual dysfunction
  • Jitteriness
  • Restlessness
  • Muscle tension
  • Tremor (can be managed by B-Blockers)
  • Akatisia (can be managed by B-Blockers)
  • Dystonia
  • Sedation
  • Exacerbation of Parkinson’s disease
  • Vivid dreams
  • Rash
  • Apathay:
    • Decreased motivation, increased passivity, lethargy
    • Management: Dose reduction; Stimulant medications; Olanzapine;
  • Reduced platelet aggregation
  • SIADH (lethargy, headache, hyponatremia, hyperosmotic urine,…)
  • Serotonin syndrome
    • Presents with: confusion, flushing, diaphoresis, tremor, myoclonic jerks…
    • Treatment: Cyproheptadine; Olanzapine
  • Discontinuation syndrome:
    • Dizziness, headache, nausea, paresthesia, diarrhea, insomnia, irritability.

Bupropion (Wellbutrin; Zyban):

  • Nausea
  • Headache
  • Insomnia
  • Anxiety or agitation
  • Seizure risk
  • Sweating
  • Gastrointestinal upset
  • Weight gain is none or little
  • Sexual dysfunction is rare
  • No seizure risk
  • Abuse of high doses: Hallucination, sinus tachycardia, seizure, loss of consciousness
  • No risk of cardiovascular or respiratory toxicity


  • Venlafaxine XR:
    • Nausea
    • loose bowel movements
    • headache
    • insomnia
    • hypertension (dose dependent)
    • Weight gain is rare
    • Sexual dysfunction
    • To avoid serotonin syndrome Venlafaxine should not be combined with MAOIs
    • Does not affect cardiac conduction
    • Does not reduce seizure threshold
    • No effect on cythochrom P450 enzymes
  • Duloxetine:
    • Nausea
    • loose bowel movements
    • headache
    • insomnia
    • hypertension (dose dependent)
    • Weight gain is rare
    • Some sexual dysfunction
    • Rare cases of increase in serum transaminase levels in the first 2 months of treatment that could result in ALT increases of three times the normal value. Should be used with caution in patients with alcohol use problem or liver diseases
    • Has been associated with Mydriasis, so should be used with caution in Narrow Angle Glaucoma patients
    • Does not affect cardiac conduction
    • Does not reduce seizure threshold
    • Duloxetine is a moderate inhibitor of cythochrom CYP 2D6 enzyme


  • Sedation
  • Priapism
  • Dizziness
  • Orthostasis
  • Weight gain is rare
  • Sexual dysfunction is rare


  • Anticholinergic effects
  • Orthostasis
  • HTN
  • Peripheral edema
  • Increased serum lipids
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction is rare


  • Insomnia
  • Orthostatic hypotension
  • Peripheral edema
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction
  • Note:
    • Avoid foods with tyramine
    • Avoid in patients with CHF
    • Be aware of potential life threatening drug interactions

Pharmacological properties


  • Blockade of Muscarinic receptors
  • Blockade of Histamine H1 receptors
  • Blockade of a1-adrenergic receptors
  • Blockade of Norepinephrine (NEP) reuptake
  • Blockade of serotonin reuptake


  • No impact on Muscarininc, H1, a1, NEP receptors
  • Only block the serotonin reuptake
  • Are much safer in overdose than TCAs
  • Unlikely to affect seizure threshold or cardiac conduction

Counseling Substance use

Encourage the patient to talk about the quitting process. Ask about:

  • Reasons the patient wants to quit
  • Concerns or worries about quitting
  • Success the patient has achieved
  • Difficulties encountered while quitting

Provide basic information about smoking and successful quitting

  • Any smoking/drug use (even a single puff) increases the likelihood of full relapse
  • Withdrawal typically peaks within 1-3 weeks after quitting
  • Withdrawal symptoms include negative mood, urges to smoke or use drugs, and difficulty concentrating

Identify events, internal states, or activities that increase the risk of smoking or relapse

  • Negative affect
  • Being around other smokers
  • Using other drugs
  • Experiencing urges
  • Being under time pressure

Identify and practice coping or problem-solving skills. Typically, these skills are intended to cope with danger situations.

  • Learning to anticipate and avoid temptation
  • Learning cognitive strategies that will reduce negative moods
  • Accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure
  • Learning cognitive and behavioral activities to cope with smoking urges (e.g., distracting attention)

Encourage the patient in the quit attempt.

  • Communicate belief in the patient’s ability to quit
  • Note that effective tobacco dependence treatments are now available
  • Note that half of all people who have ever smoked have now quit

Communicate caring and concern.

  • Ask how the patient feels about quitting
  • Directly express concern and willingness to help
  • Be open to the patient’s expression of fears of quitting, difficulties experienced, and ambivalent feelings.

Carpal Tunnel Syndrome


Carpal tunnel syndrome is a painful condition caused by compression of a key nerve in the wrist.   It occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. Symptoms usually start gradually, with  pain, weakness, or numbness in the hand and wrist, radiating up the arm.  As symptoms worsen, people might feel tingling during the day, and decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks.  In some cases no direct cause of the syndrome can be identified.   Most likely the disorder is due to a congenital predisposition – the carpal tunnel is simply smaller in some people than in others.  The risk of developing carpal tunnel syndrome is especially common in those who preform repetitive work tasks, such as assembly line work. Carpal tunnel syndrome is also associated with pregnancy and diseases such as diabetes, thyroid disease, or rheumatoid arthritis.

Risk factors


  • Localized repetitive trauma
  • Occupational
  • Forced wrist flexion


  • Thyroid Dysfunction
  • Hypothyroid
  • Pregnancy
  • Acromegaly
  • Gout

Inflammation and/or infection:

  • Infiltrative disorders such as amyloidosis
  • Sarcoidosis
  • Inflamatory tenosynovitis
  • Soft tissue infection

Differential diagnosis

  • Cervical spine disease
    • OA
    • Stenosis (C6, C7)
    • Disc herniation
    • Brachial plexus neuropathy
  • Median nerve compression in the arm or forearm
  • Mononeuritis multiplex
  • Cervical cord abnormalities
  • Angina pectoris
  • Thoracic outlet
  • Pancoast tumor
  • TIA
  • Tendonitis


  • Pain distal to lesion
  • Burning paresthesia/dyesthesia
  • Awakens at night with numbness
  • Pain may radiate to shoulder
  • Pain is relieved by shaking, dangling, rubbing
  • Sensory loss (median nerve distribution – 1st 3.5 fingers)
  • Muscle weakness
  • Muscle wasting
  • Hemiparesis, dysarthria, visual changes, HA, neck pain (R/O DDx)

History taking

  • Onset, progression
  • Motor, sensory or autonomic dysfunction
    • Ahnydrosis
    • GI dysmotility
    • Impotence
    • Bladder
    • Pupils
  • Mononeuropathy vs. polyneuropathy
  • Proximal vs. distal
  • Upper vs. lower extremity
  • Associated disease
    • Rheumatoid
    • Diabetes
    • Hypothyroid
    • Acromegaly
    • Vasculitis
    • Amyloidosis
    • Pregnancy
    • Post-injury
    • Alcohol abuse
  • Occupational History:
    • Type and nature of occupation
    • Length of time in that job
    • Total number of hours worked each in that job

Physical exam

  • Examine c-spine & shoulder
  • Examine joint above and below
  • Examine forearm
  • Examine wrist
  • Finger exam
  • Compare both sides
  • Inspection
    • Muscle wasting thenar muscles (late)
    • Asymmetry
    • Fasciculations
    • Swelling
    • Erythema
  • Palpation:
    • Tenderness
    • Anatomical snuffbox
    • Crepitus
  • Sensory:
    • Decreased light touch in thumb, index finger or middle finger
    • Decreased 2 point discrimination (> 6 mm)
    • Vibration
    • Position
    • Temperature
  • Motor:
    • ROM
    • Weakness thumb in flexion (flexor pollicis longus)
    • Weakness in extension
    • Finger movements
  • Special tests:
    • Tinel’s sign (Tap of nerve on wrist ® Tingling from wrist to hand)
    • Phalen’s sign (wrist flexion 90 degrees x 1 min ® numbness, dysethesias in median distribution)
    • Carpal compression test (pressure on carpal tunnel for 30 sec elicits symptoms)

Laboratory work up

  • CBC
  • ESR
  • Fasting Blood Suger
  • Rheumatic Factor
  • TSH
  • Uric acid
  • HbA1c
  • Pregnancy test

Diagnostic tests

  • CXR
  • NCV
  • EMG


Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, other nonprescription pain relievers, and oral steroids (prednisone) may ease pain. Steroid injections can also be used to alleviate the swelling and pressure on the median nerve. For more severe cases of carpal tunnel syndrome, open carpal tunnel release surgery or endoscopic carpal tunnel release may be recommended.

The followings can be considered in treatment  of CTS:

  • Minimize wrist movement
  • Improved occupational and workplace ergonomics
  • Splinting:
    • Neutral wrist splint at bedtime
  • Lasix
  • Corticosteroid injections (50-80% effective)
  • Surgery Indications:
    • refractory pain
    • +++ sensory loss
    • muscle atrophy
  • Release flexor retinaculum (>90% effective)
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