Rheumatology/Orthopedic Buzz Terms

Rheumatology. I'm not sure there is a more gray area of medicine... perhaps that's why I don't like it that much. I remember sitting in rheumatology class listening to cases thinking, "it could be any of the rheum diseases that we've talked about!" They all sound the same and there is no ONE test that gives you the answer. I find it immensely frustrating (perhaps why I ended up in a surgical field), but I tip my hats to the providers that work in it. It is so difficult to pin down a diagnosis and successfully treat a patient with rheum issues... so for me, I stick to the basics.

See below for my knowledge extent on these rheum/orthopedic PANCE/PANRE test-able gems:

Osteoarthritis (OA)
Exercise, PT
If knee joints involves - encourage weight loss indicting
Pool activities

Rheumatoid arthritis (RA)
Aspirin, other NSAIDS
methotrexate for severe cases
benefits take months to see after therapy initiation

Ankylosing Spondylitis
Bamboo spine on plain films

NSAIDs for joint symptoms
Benign cases only need supportive care
Systemic corticosteroids for serious complications
Could be a cause of thrombosis in young women (oral contraceptives can also cause this)

Vit D deficiency

Aspirate and culture
Generally start with IV antibiotics then follow with PO antibiotics

Source: Medical boards Step 2 Made Ridiculously Simple - A. Carl, MD, PhD
Photo: wiki.cns.org


Postoperative management of temporal lobectomy

Postoperative management of temporal lobectomy:
  1.     OR to PACU x 1 day to floor x 1-2 day – aim for D/C on POD3
  2. ·      Early rise in body temp post op, think about incentive spirometery
  3. ·      Hep lock as soon as patient starts taking PO fluids
  4. ·      Encourage sitting and ambulating
  5. ·     Patient remains on preop AEDs for 1-2 years post op (managed by Epilepsy folks)

·      Possible complications to look for:
o   Hemiparesis
§  Usually happens after cauterization/tearing of perforating vessels (from posterior communicating vessels or anterior choroidal a.)
§  Paralysis usually occurs immediately – this would be known before post op check
o   Visual field defects
§  Contralateral superior quadrant anopsia from damage of the Meyer loop
§  Always check visual fields
o   Dysphasia
§  Usually transient (1-3 weeks post op)
§  Approx 50% of dominant temp. lobe resections have dysphasia
o   Aseptic meningitis
§  A complication that usually presents 72 hrs – 1 week post op
§  Stiff neck, severe HA, nausea, elevated body temp
§  Diagnosis of exclusion with LP
o   Post operative seizures
§  Sz w/in 1st 24hrs does not correlate to poor long term outcomes

§  Sz after 48hrs (with adequate AED blood levels) indicate poor long term outcome

Source: Neurosurgical Operative Atlas 2nd Ed- Starr, Barbaro, Larson
Pic source: http://www.neuros.net/en/epilepsy_surgery.php


Preoperative Patients on Coumadin

If you work in surgery or with the elderly - anticoagulation is an every day part of life. INRs, PTs, PTTs, etc... it is important to know what measures what and what reversal agents (if any) are available. Let's talk about Coumadin today.

Scenario: 79 yo patient is coming in for a surgical procedure, but he is on Coumadin. You did your due diligence and had them stop it about 5 days pre-op, but their INR is still 1.6 on preoperative blood work. What are your next steps?

Generally if you are going to bring someone to the OR you'd like their INR to be less than 1.5. If it is higher, you would consider a reversal agent.

Your 1st option for reversal is Vit K
  • PO is most predictable and is preferred to IV if rapid reversal is not needed. PO Vit K lowers INR in about 24-48 hours. 
  • IV works in approximately 12-24 hrs, but you run a greater risk of anaphylaxis and it must be administered over a longer period of time (approx 20 minutes). 
Your 2nd option for reversal is Fresh Frozen Plasma (FFP).
  • FFP is more expensive than Vit K, but works within 12 hrs. FFP replaces clotting factors.
So, even though you did your due diligence, why was the INR still high? There are several reasons that can delay the drop of a patient's INR:
  1. Age - Elderly pts
  2. Malignancy (active)
  3. Liver disease
  4. CHF, unstable
  5. Meds that keep Coumadin around in the blood (check their med list)

Ansell, J, Hirsh, J, Poller, L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:204S. 

Normalization of INR After Stopping Coumadin: http://www.fpnotebook.com/mobile/HemeOnc/Surgery/PrprtvAntcgltn.htm


Surgical Training for Neurosurgical PAs

Last week I had the privilege of attending a surgical training in San Francisco, California. The event was created by the Association of Neurosurgical Physician Assistants (ANSPA) in conjunction with Ethicon. I must say it was a fantastic experience. I was able to spend a half a day in a live porcine wet lab. The lab was for PAs only so it enabled me to spend more time with the surgical instruments and take the lead on certain aspects of the surgeries that we performed - both opportunities that I don't necessarily get on a day to day basis. It was successful in building my confidence.

We performed a craniotomy and tumor removal as well as a laminectomy with a focus on hemostasis. This is an unusual experience and I learned a great deal from both the PAs that attended and the Ethicon reps regarding hemostasis products. I had the least amount of surgical experience of all the PAs that were there (9 months), however all of the PAs were friendly and helpful and I learned quite a few new techniques. It was also inspirational to see what other PAs around the nation were doing as part of their daily grind. It ranged from PAs that spent the majority of their time in the OR as co-surgeons to those that split their time 50-50 between OR and floor work.

I was able to meet and spend some time with Josh, a neurosurgical PA for over 10 years, who is the current president of ANSPA. The AAPA recently completed a video on him and his contributions to his neurosurgical practice. The surgeons that he works with on a daily basis speak very highly of his surgical and patient skill sets. Mike Nido, PA-C and Dean Barone, PA-C were also instrumental in making this event happen.

All in all, hats off to ANSPA for working hard to make this happen for PAs. They hope to create more of these learning opportunities for neurosurgical PAs in the near future. If you are not a member, I highly encourage you to do so if you're interested in neurosurgery as a physician assistant.

*Disclosure: I am in no way financial tied to Ethicon. Just attended the event.


Antibiotics for Appendicitis?

I have had quite the hiatus from blog entries recently. Life gets busy somehow. Ha. I recently had hip surgery and had some blog worthy experiences as a patient that I hope to write about soon - but for now, I came across this interesting article on a PA (Andrew Gray, PA-C) that refused an appendectomy in lieu of antibiotic treatment for his acute appendicitis. He made his choice based on the fact that he did not have insurance and the results of a Swedish study. It is a short read, but very interesting and have evoked some feisty comments.

Saving My Appendix: http://www.pulsemagazine.org


Passing the Time on the T with JAAPA

So the PA Journal (JAAPA) now has an application for the iPad. It has been out for a while now and I really like it! I download the most recent journal and am able to read it on the T on the way to work. It is great... it helps me keep up on the newest issues and clinical articles. The only downside is that it is only for the iPad currently... sorry no iPhones or iPods.

If you are an AAPA member, you get the journal for free along with the free CMEs in each issue.

Down load it at the Apple App Store:  Journal of the American Academy of Physician Assistants



I have always found aphasia incredibly interesting and terrifying all at the same time. Imagine not being able to communicate with language as smoothly as you do everyday. It is something that many of us take for granted.

the loss or defect of language (speaking fluency, reading, writing, understanding of written or spoke words)

What are the 4 types of aphasia?
1. Wernicke's 
2. Broca's
3. conduction
4. global

Potential causes:

  • stroke
  • brain trauma
  • brain tumor
  • alzheimer's disease
-receptive, fluent aphasia
-pt has hard time comprehending written or spoken language
-fluid speech, but difficult to understand

-expressive, nonfluent aphasia
-speech is slow and requires effort
-few words used
-good comprehension of language

-disturbance in repetition
-pathology involves the connections between Wernicke's and Broca's

-often associated with RIGHT hemiparesis
-defect in all areas of language

How to treat
-many recover spontaneously in 4-6 weeks
-speech therapy

Photo source: emedia.leeward.hawaii.edu
Source: Step Up to Medicine by Agabegi and Agabegi


ACA Stroke Basics

Anterior Cerebral Artery (ACA) Stroke

The Anatomy

What deficits might you expect to see in a patient?

  • contralateral leg weakness (both motor and sensory), frontal lobe behavioral issues, +/- aphasia if prefrontal cortex involved, grasp reflex
Where does the ACA receive its blood supply from?
  • Carotid arteries

Source: http://www.neuroanatomy.ca/stroke_model/aca_info.html
Photo sources: http://missinglink.ucsf.edu/lm/ids_104_cns_injury/response%20_to_injury/watershed.htm



As always... back to the basics:

What is oliguria?
Low urine output (UOP)

What is "normal" adult UOP?
About 30cc/hr

How might you write a post op floor order for this?
"call house officer if 2 hour UOP is < 60cc"

What are the possible causes?
Think pre renal/renal/post renal causes

What is the most common cause?
Pre renal!


Causes of Renal Failure

Causes of Renal Failure broken down by pre-renal, renal, and post-renal.

Source: Clinical Survival Guide for PA Students by G.Broughton, MD, PhD


What if PAs Couldn't Suture Anymore?

This a repost from a call sent out by the AAPA based on a resolution brought to the AMA's House of Delegates. Read it and take part in your future scope of practice as a PA.

Join AAPA in responding to negative AMA resolution

While workforce experts are predicting a shortage of providers with the implementation of the Affordable Care Act, the American Medical Association Board of Trustess is proposing a resolution for its House of Delegates that could severely restrict PAs' ability to provide care to patients. PAs should be very concerned about the resolution, which will be considered by the AMA HOD when it convenes on Saturday, June 15. The recommendations are very restrictive and display a misunderstanding of the way PAs and doctors provide care as part of a team. Among other restrictions, the resolution expands the definition of surgery to include repair and removal of human tissue and, although parts of the resolution are somewhat unclear, states that surgery as defined in the resolution is to be performed ONLY BY PHYSICIANS. If adopted as presented, the resolution will call into question procedures like suturing, punch biopsies and vein harvesting, which PAs perform on a daily basis across many medical specialties. The resolution also proposes that only physicians should perform invasive procedures that utilize radiologic imaging. You can read Report 16 of the AMA Board of Trustees in full here.

AAPA is spreading the word about the negative impact this resolution would have on patient care and PA practice, but we need your help. Please review the list of AMA delegates in your state or specialty, and if you have a connection, please let that physician know the true damage that this resolution could create. Also, talk with and encourage physicians in your practice to speak with other physician leaders about the resolution. AAPA's suggestion is that the resolution should be defeated, or modified to specifically state that it does not apply to PAs practicing within the parameters of state law.

For more information on the AMA resolution please contact Ann Davis, PA-C, MS, Senior Director of Constituent Organization Outreach and Advocacy, at ann@aapa.org.


The PA Mentoring Project

While I was at the national AAPA conference in May in Washington DC, I learned about a new mentoring project that was recently launched. It is called the National Physician Assistant Mentoring Project. Their tagline is "PAs helping PAs". It was started by Robert Smith, PA–C and Habia Collier, PA–C.

The idea is to have more seasoned PAs be mentors for younger/new to the field PAs and PA students. These two physician assistants were very passionate about this program when they came to speak to the AOR.

This mentoring project is in its infancy, however it needs more PAs that are willing to be mentors in order for it to grow.  Check out their website at: www.PAmentoring.org

Hats off to these two for getting such a great idea up and running!

Pic Source: www.euphoricbirth.com


Free AAPA app

The AAPA has developed an app! They officially launched it at conference and I wanted to give you a little overview. Cost: FREE
Easily accessible links to JAAPA, PA Professional, the PA microsite, and Joblink!

Keep up with the social media buzz and the trending #hashtags.

Keep up with the latest news in the AAPA profession.


PA MAN - I Love Conference!

This, in a nutshell, is why I love conference. PAs know how to have fun. Hope to see everyone there in Boston next year! Check out the video...


Atrial Fibrillation

AFib, The Basics

  1. irregularly iregular
  2. irregular RR intervals
  3. not a P wave in front of every QRS
  4. atrial rate = 400-600bpm, ventricular rate = 80-160bpm
Etiologies = PIRATES
P = pulmonary (COPD, PE)/pheo/pericarditis
I = ischemic heart dz +/- HTN
R = rheumatic heart dz
A= anemia/atrial myxoma
T = throtoxicosis
E = ethanol ("holiday heart)/cocaine
S = sepsis (post-operative)

  1. fatigue (most common)
  2. tachypnea
  3. palpitations
  4. lightheaded

Work Up
(Test yourself... why would you order each of these? what are you looking for?) - answers below
  1. EKG
  2. ECHO
  3. TSH (?)
  4. Baseline coags

  1. EKG = narrow complex QRS (<120msec), variable RR, irregular or absent P waves
  2. ECHO = maybe thrombi, maybe dilated L atrium
  3. TSH (?) = hyperthyroidism can cause AF
  4. Baseline coags = getting baseline prior to starting anticoagulation

Of note: if you are looking for THROMBI..."normal" ECHOs (transthoracic) has low sensitivity - transesophageal ECHOs allow for better visualization of L atrial appendage (location where most thrombi form) 

source: First Aid for the Wards by Le, Bhushan, Skapik
pic source: http://www.saintvincenthealth.com/Services/Heart/Heart-Resource-Library/Atrial-Fibrillation/default.aspx


Diabetes Insipidus, Part 2

Diagnosing DI

Polyuria = urine vol > 3L in 24 hrs - there are many causes of polyuria and it is important to figure out if the cause is DI or something else prior to establishing treatment

Urine osmolality (osm) of > 300 mOsmol/kg + high serum glucose --> think diabetes mellitus
Urine osmolality (osm) of > 300 mOsmol/kg + high serum urea --> think renal dz
Urine osmolality (osm) of < 200 mOsmol/kg + polyuria --> think DI

So you have a patient that has urine ohm < 200 + polyuria and you are thinking DI... how do you differentiate between central DI and nephrogenic DI?

Answer: water deprivation test

Central DI
urine osm < plasma osm after dehydration
after ADH injections urine osm increases by >50%

Psychogenic DI

urine osm > plasma osm after dehydration
after ADH injections urine osm increases minimally

Nephrogenic DI

urine osm < plasma osm after dehydration
after ADH injections urine osm increases by <50%

Makaryus/Mcfarlane. DI: diagnosis and treatement of a complex disease Cleveland Clinic Journal of Medicine Jan 2006 Vol 73:1
pic source: medicaltextboks.blogspot.com


Old and New Blog Entries

I have had several people email asking me to make it easier to find "old" posts. I have converted the dated section to include "Titles" as well. Hope this helps!

You can also look under the different "Themes".

If you aren't finding what you are looking for... shoot me and email and I will working on adding a post to answer your question.

Upcoming topics from emails received include the following:

-Suturing techniques
-Scubbing in for the 1st time
-Better note writing tips
-Making the best out of your rotations
-Important neurosurgical exam findings


Blog for Women in Surgery

I recently came across this blog... seems to just be starting up, but has lots of promise. I've added it to my favorites list.


Diabetes Insipidus, Part 1

Diabetes Insipidus, Part 1

What is it?

  • The inability to conserve H20 and maintain optimum free H20 levels
  • Pts urinate large amounts of diluted fluid, regardless of the body's hydration state
  • Sx: extreme thirst (can even wake pts up at night and drink up to 20L per day!), dry skin, constipation

Click to enlarge

Part 2: Diagnosing DI
Part 3: Treatment for Central DI and Nephrogenic DI

Makaryus/Mcfarlane. DI: diagnosis and treatement of a complex disease Cleveland Clinic Journal of Medicine Jan 2006 Vol 73:1


Important Differentiation in Small Bowel Obstruction (SBO)

Small Bowel Obstruction

There are 3 main pts of differentiation to consider with SBO...

Click to enlarge


Calculating and Interpreting ABI

First things first...
What does ABI stand for? 

Ankle-Brachial Index

What arteries are you examining?

Brachial and Dorsalis pedis

How do calculate ABI?

R ABI = highest avg ankle pressure (R dorsalis pedis)/ highest avg arm pressure (either arm)
L ABI = highest avg ankle pressure (L dorsalis pedis)/ highest avg arm pressure (either arm)

How do you interpret the #s?

ABI                     Interpretation
>0.90                   Normal LE flow
<0.89 - >0.60      Mild PAD
<0.59 - >0.40      Moderate PAD

<0.39                   Severe PAD

See more about the technique of gathering ABI data in an older ABI post of mine...

Source: Bates Pocket Guide of Physical Examination 6th Ed


Differentiating the Shakes

Essential Tremor v. Parkinson's Disease, Simplified

Of course this topic could be covered in much more depth than shall be covered here... but this is designed to cover the big picture and help you study for the PANCE.

Characteristic: postural and/or intention tremor, meaning when the patient attempts to do something with their arms, the tremor appears or gets worse... these patients have difficulty with eating and drinking. 
Treatment: propranolol and primadone
Other notes: ETOH usually makes tremor BETTER, 50% of pts have a + family hx, tremor can affect voice (remember to ask the pt to say "EEEEEEEEEEE" - you often hear shaking)

Characteristic: resting tremor
Treatment: sinamet, levodopa-carbidopa
Other notes: other PD sx = bradykinesia (slow movements), cog wheeling with passive movements

Source: Hardcore Pathology, by Wahl


Perinatal Infections

Perinatal Infections...


Other (syphillis) - I always hate when "other" is one!

Source: Hardcore Pathology by Wahl


PANCE Study Material: Male Reproductive Jargon

PANCE Study Material: Male Reproductive Jargon

HypOspadias = abnormal urethral opening underneath (remember hypO means "below")
Epispadias = abnormal urethral opening above (remember epi means "above")

*Phimosis = foreskin is too tight to retract over glans
*Paraphimosis = foreskin is too tight to return back to its usual position

*Usually congenital, but can be caused by trauma or infectious scarring

Source: Hardcore Pathology by Wahl


Retractors and Suckers, Student Life in the OR

Most PA students go through some surgical rotation during their schooling... and let's be honest, with the rare exception of an end-of-the-rotation treat, many students do little more than retract and suck. Although frustrating at times, this isn't a bad thing. We all need to crawl before we walk. The surgeons that you will be working with have several years of experience - you can't expect to participate in a major surgery with 3 days of surgical experience

I suggest that you take each opportunity to watch the surgeons closely (don't just stare off or focus solely on the anatomy). How do they hold the scalpel? Do they apply tension to the skin? Which way to they cut? Which tool do they use and when? You will pick up more than you think and when given your opportunity to participate- you will at least have a clue what to do.

Frazier suckers (different sizes)
Below are some instruments that you may see during your rotations. The pics are from an OR Instrument book. I don't see a real need to purchase the whole book because its coverage of surgical instruments is too wide spread.... it is better for an OR Tech who may be working with cardiology, orthopedic, neurosurgical, etc kits. It is, however, worth checking it out of the library to browse through before or during your surgery rotation.

Adson tissue forceps

Ferris Smith tissue forceps

DeBakey vascular forceps

Left --> Right: Goelet retractors, Army Navy retractors, Richardson retractors (med, large)

Source:  Instrumentation for the Operating Room: A Photographic Manual, 7e Shirley M. Tighe RN BA


NHSC Loan Repayment Webinar

Looking to utilize the NHSC to take care of some of your student loans? NHSC just put out a webinar explaining all of the rules/regulations associated with partaking in the Loan Repayment program.


Malignancy Buzz Words

What are the sign/sx and the associated diagnosis with the following buzz words?

(Answers below)

1. Virchow's node

2. Pancoast's

3. Lambert-Eaton

4. Trousseau's

5. Peau d'orange


1. Virchow's node = palpable supraclavicular nodes [associated dx: stomach cancer]
2. Pancoast's = shoulder discomfort, Horner's syndrome [associated dx: apical lung tumors]
3. Lambert-Eaton = myasthenia [associated dx: small cell carcinoma]
4. Trousseau's = thrombophlebitis [associated dx: adenocarcinoma (breast, lung, prostate)]
5. Peau d'orange = edematous thickened breast skin [associated dx: late stage breast CA]

Pic sources: http://www.netterimages.com/image/10287.htm, www.studyblue.com, http://www.bmj.com/content/336/7656/1298?ijkey=kN/189nWkD8aw&keytype=ref&siteid=bmjjournals

Source: Medical Boards Step 2 Made Ridiculously Easy - Andreas Carl, MD


Heart Failure

Quick study material on heart failure:

  • dyspnea
  • wheezing
  • orthopnea
  • S3/S4 gallop
  • puLsus alternans
  • peripheral edema
  • nocturia
  • JVD
  • hepato/spleno-megaly
FUNCTIONAL CLASSES (1 = best, 4 = worst)

Pic source: http://www.remodulin.com/patient/diagnosing-pah.aspx
Source: Medical Boards Step 2 - Made Ridiculously Simple (Andreas Carl, MD)


Would You Treat People Differently If You Knew What They Were Thinking?

The Cleveland Clinic put together a pretty amazing video on "Empathy" - it addresses all of the different people, their thoughts, and issues -- Would you treat people differently if you knew what they were thinking?

This video can be viewed at: http://www.youtube.com/watch?feature=player_embedded&v=cDDWvj_q-o8


Placing External Ventricular Drains

What is an EVD?
A temporary system that allows drainage of CSF from the ventricles to an external closed system.

Caring for a patient undergoing EVD placement Great clinical guideline series by the American Association of Neuroscience Nurses

Preventing Infections When Placing EVDs (video)

Potential placement sites:

Paine's Point

Fraizer's Point

Kocher's Point

If you are having trouble uploading the video, here is the link: http://www.youtube.com/watch?v=x49rY0tZpVI

Pic source: http://www.brain-surgery.us/Drain_Placement.html#kocher


Transcranial Doppler

How does a transcranial doppler work?

  • uses low-frequency U/S to evaluate flow velocity in cerebral vessels

Why might you order a transcranial doppler?

  1. evaluation of basal cerebral arteries
  2. finding spasms intercranially
  3. evaluating the patency of the MCA (you would look for this in patients with carotid stenosis)
What the upside to transcranial dopplers?
  1. no radiation
  2. fast
  3. non-invasive
  4. can evaluate the circle of willis/intercranial carotids
What is the downside?
  1. the outcomes is dependent on the person doing the test - skill and bias can play a role
Transcranial Doppler Video (a little old school - but good information)

Pic source: http://spencertechnologies.com
Source: Ferri's Best Test: A practical guide to clinical lab and medicine diagnostic imaging, Fred Ferri


Hematuria Workup

A diagnostic algorithm to consider when working up hematuria...

click on picture to enlarge

Source: Ferri's Best Test: A practical guide to clinical lab and medicine diagnostic imaging, Fred Ferri


IV Therapy Complications

"Let's give him/her some IV fluids." Seems like a simple enough order. IV therapy is part of medicine, but it is not without risks. It is important to know the risks so that you know what complications to look for in the seconds, hours, days after an IV has been started.

Thrombophlebitis - usually manifests with erythema, inflammation, and/or pain at the IV site (think about changing the IV q3 days to help prevent this)

Infiltration - this happens when whatever you are giving through the IV (meds/fluids) starts to leak into the surrounding tissue (this can cause a big problem - compartment syndrome - if the volume is large enough)

Blockage - something, a blood clot for example, can clog the IV making it unusable (flushes can help minimize the risk of this)

Air embolus

Source: Step up to Medicine 2nd ED Agabegi and Agabegi
Pic source: http://en.wikipedia.org/wiki/Intravenous_therapy


In Honor of Dr. C. Everett Koop

Dr. C. Everett Koop, former Surgeons General, 1937 graduate of Dartmouth, and founder of the C. Everett Koop Institute at the Geisel School of Medicine died peacefully at his home in Hanover this afternoon.

I had the distinct pleasure and honor of meeting and dining with Dr. C. Everett Koop at a Dartmouth event a few years back. In addition to his numerous contributions to medicine, he was a kind man with great stories to share. 

He pioneered numerous advances in pediatric surgery, and trained and mentored many of the leaders now in this field. As one of our country’s greatest Surgeons General, he effectively promoted health and the prevention of disease, thereby improving millions of lives in our nation and across the globe. He founded the C. Everett Koop Institute at Dartmouth to transform healthcare and the process of educating health professionals.

To read more about Dr. Koop’s life and pioneering contributions to our world, please see: http://geiselmed.dartmouth.edu/koopmemoriam/.


Carpal Tunnel

Carpal Tunnel

See below for the answers.

What nerve is compressed in carpal tunnel?
What population is it most commonly seen in?
What are typical signs and symptoms?
Where is the anatomical location of the "carpal tunnel"?
Work up?

What nerve is compressed in carpal tunnel?
Median nerve

What population is it most commonly seen in?
Women 30-50 years old

What are typical signs and symptoms?
Wrist pain - numbness/tingling of thumb
Pain exacerbated with activities of wrist flexion
May awaken pt at night
Thenar atrophy

Where is the anatomical location of the "carpal tunnel"?
Between the carpal bones and the flexor retinaculum

Work up?
Clinical exams: Tinel's sign and Phalen's sign
EMG/nerve conduction study

neutral wrist orthosis
modification of activities that irritate
NSAIDs for inflammation control
steroid injections

Source: First Aid for the Wards (Le, Bhushan, Skapik)
Photos: www.methodistorthopedics.com , http://en.wikipedia.org/wiki/File:Carpal_Tunnel_Syndrome,_Operation.jpg