What is the appropriate initial evaluation and management for a patient presenting with numbness and tingling sensation in both hands, without a clear history of trauma or systemic disease?

SOAP Note: Bilateral Hand Numbness and Tingling

Subjective

Document the following specific symptom characteristics:

• Distribution pattern: Determine if numbness follows median nerve distribution (thumb, index, middle, and radial ring fingers) suggesting carpal tunnel syndrome, versus symmetric bilateral involvement of all fingers suggesting systemic neuropathy 1, 2

• Temporal pattern: Ask if symptoms worsen at night or during rest, which is characteristic of carpal tunnel syndrome, versus constant symptoms suggesting peripheral neuropathy 1, 2, 3

• Progression: Establish whether symptoms started in feet first (typical of length-dependent neuropathy) or began in hands, and whether progressing proximally 1

• Associated symptoms: Screen for burning sensations in forearms (suggests central cord syndrome requiring urgent imaging), weakness, pain severity on 0-10 scale, and any lower extremity symptoms 1, 4

• Red flags: Ask about acute onset (stroke concern), unilateral face/arm/leg involvement, speech disturbance, visual changes, coordination problems, bowel/bladder dysfunction, or gait instability 1, 4

• Risk factors: Document diabetes duration and control (HbA1c), alcohol use quantity, chemotherapy exposure (specific agents and timing), thyroid disease, vitamin supplementation, family history of neuropathy, and occupational hand/arm use 1, 5

Objective

Physical examination must include:

• Sensory testing: Perform pinprick sensation, temperature perception with cold tuning fork, vibration testing with 128-Hz tuning fork on fingertips bilaterally, and 10-g monofilament testing 1, 4

• Motor examination: Test thumb opposition strength, assess for distal weakness in hand intrinsic muscles, check for muscle atrophy in thenar eminence, and examine ankle/toe dorsiflexors 1

• Reflexes: Test biceps, triceps, brachioradialis, and ankle reflexes bilaterally; reduced or absent reflexes indicate peripheral neuropathy 1

• Provocative maneuvers: Perform Durkan test (firm digital pressure across carpal tunnel for 30 seconds to reproduce symptoms; 64% sensitive, 83% specific for CTS) 2

• Gait assessment: Observe for wide-based unsteady gait indicating proprioceptive loss 1

• Cervical spine examination: If any burning dysesthesias in forearms or lower extremity symptoms present, this becomes urgent 4

Assessment

The differential diagnosis prioritization is:

1. Carpal tunnel syndrome if symptoms are in median nerve distribution, worse at night, and Durkan test is positive 2, 6

2. Diabetic peripheral neuropathy if patient has diabetes and symmetric stocking-glove distribution 1, 5, 4

3. Cervical myelopathy/central cord syndrome if bilateral hand numbness with burning forearm dysesthesias or any lower extremity involvement 4

4. Chemotherapy-induced peripheral neuropathy if recent chemotherapy exposure (platinum compounds, taxanes, vinca alkaloids) 7, 5

5. Metabolic/toxic neuropathy from B12 deficiency, hypothyroidism, or alcohol 1, 5

Plan

Immediate Actions

Order urgent cervical spine MRI same day if:

• Bilateral hand numbness accompanied by burning dysesthesias in forearms 4
• Any lower extremity symptoms present 1, 4
• Gait disturbance or hyperreflexia noted 1

Refer for same-day stroke assessment if:

• Acute onset with hemibody sensory loss, unilateral face/arm/leg involvement, speech disturbance, visual changes, or coordination problems 1

Initial Laboratory Testing

Order the following labs for all patients:

• Fasting glucose and HbA1c 1, 5
• Complete blood count 1
• Vitamin B12 level 1, 5
• Thyroid-stimulating hormone (TSH) 1, 5

Consider additional testing based on clinical suspicion:

• Hepatitis B, C, and HIV if risk factors present 5
• Serum protein electrophoresis if concern for paraproteinemia 5

Electrodiagnostic Studies

Order nerve conduction studies and EMG when:

• Clinical features are atypical for carpal tunnel syndrome 1
• Diagnosis remains unclear after initial evaluation 1
• Need to differentiate axonal versus demyelinating neuropathy 1
• Suspected proximal compression or other compressive neuropathies 2

Note: Nerve conduction studies are >80% sensitive and 95% specific for carpal tunnel syndrome 2

Imaging

For suspected carpal tunnel syndrome with normal or indeterminate examination:

• Ultrasound of wrist or MRI without contrast are equivalent first-line imaging options 7

For chronic hand symptoms with concern for tendon pathology:

• Ultrasound or MRI without contrast are appropriate 7

Initial Treatment

For carpal tunnel syndrome:

• Wrist splinting in neutral position at night is first-line conservative therapy 2
• Corticosteroid injection may provide temporary relief 2
• Refer for surgical consultation (open or endoscopic carpal tunnel release) if conservative measures fail 2

For peripheral neuropathy:

• Duloxetine 60 mg once daily is first-line pharmacologic treatment for neuropathic pain 5, 4
• Can increase to 120 mg daily if needed 5
• Gabapentin or pregabalin are alternatives 5
• Recommend regular physical activity for symptom improvement 5, 4

For diabetic neuropathy specifically:

• Optimize glucose control to prevent progression (does not reverse existing damage) 5, 4
• Target individualized HbA1c goals 5
• Screen annually for progression 5

Follow-up

• Reassess symptoms before every treatment cycle if chemotherapy-related 7
• Monitor for development of foot ulcers in diabetic patients 5
• Refer to neurology if diagnosis remains uncertain after initial workup or if symptoms progress despite treatment 1

Critical Pitfalls to Avoid

• Do not delay cervical spine imaging if bilateral hand symptoms are accompanied by burning forearm dysesthesias or any leg symptoms - this represents central cord syndrome until proven otherwise 4
• Do not assume bilateral hand numbness is always peripheral neuropathy - consider cervical myelopathy 4
• Do not order EMG/NCS for typical carpal tunnel syndrome presentation - clinical diagnosis with Durkan test is sufficient to initiate conservative treatment 2
• In diabetic patients, do not attribute all numbness to diabetes without screening for B12 deficiency, hypothyroidism, and other treatable causes 5, 4