History Taking · Foundation · Rheumatology

Hand Numbness and Tingling in a 52-Year-Old Woman

Practise this PLAB 2 history taking station on Carpal Tunnel Syndrome. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Erin Crichton, a 52-year-old woman, has come to see you with numbness and tingling in both hands that started gradually over the past three months. The symptoms are worse at night and affecting her sleep. She has classic signs and symptoms of carpal tunnel syndrome. Please take a focused history and discuss management options including nerve conduction studies.

Background notes: PMH: Hypothyroidism

What this station tests

  • Localising to median nerve distribution: thumb, index, middle, and radial half of ring finger, not the little finger
  • Nocturnal worsening and the flick sign as highly specific features of carpal tunnel syndrome
  • Identifying hypothyroidism as a contributing factor: CTS is associated with hypothyroidism, and adequate thyroid replacement may improve symptoms
  • Assessing severity: thenar wasting and thumb weakness indicate advanced CTS requiring surgical referral
  • Conservative management: night splints as first-line, keeping wrist in neutral to prevent compression

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Carpal tunnel stations test the candidate's ability to localise symptoms to the median nerve distribution and identify contributing factors. The pattern, nocturnal paraesthesia in thumb, index, middle, and radial ring finger, is highly specific. Mrs Crichton is 52, presenting with 3 months of bilateral hand numbness and tingling, worse at night, affecting her work as a graphic designer. Open with: 'Mrs Crichton, tell me about the numbness and tingling and which fingers are affected.'

Core approach

Localise to median nerve distribution. The symptoms are in her thumb, index, middle, and radial half of ring finger. Not the little finger (ulnar nerve territory). This distribution is diagnostic. Ask specifically: 'Which fingers are affected?' If she says 'all of them,' ask her to point to exactly where the numbness is worst.

Nocturnal worsening is the hallmark. She is woken by numbness and has to shake her hands to restore sensation ('flick sign,' which is highly specific for CTS). Ask about what makes it worse: repetitive hand use (she uses a computer and drawing tablet all day), holding a phone, gripping. What helps: shaking hands, running them under warm water.

Identify contributing factors. She has hypothyroidism (hypothyroidism is a recognised cause of CTS, check if adequately treated with recent TFTs). Other associations: pregnancy (not applicable), diabetes (check), RA (check for joint symptoms), obesity. Occupational: repetitive hand movements as a graphic designer.

Assess severity. Thenar wasting? Weakness of thumb opposition? If present, this indicates advanced CTS needing surgical referral. If absent, conservative management is appropriate initially.

Closing and safety netting

Explain the diagnosis: 'The pattern of numbness in your thumb, index, and middle fingers, worse at night, is caused by compression of the median nerve as it passes through a narrow tunnel in your wrist. This is called carpal tunnel syndrome.' Explain it is common and treatable.

Conservative management first: wrist splints at night (keeping the wrist in neutral prevents nocturnal compression). Check and optimise thyroid replacement (if hypothyroidism is contributing). Ergonomic advice for her workstation. NSAIDs for pain. If conservative measures fail after 6 to 8 weeks: nerve conduction studies to confirm, then consider corticosteroid injection or surgical decompression.

Address her work concern: 'With the right management, most people continue working without problems. The splints at night are usually the most effective first step.' Safety net: 'If you develop weakness in your thumb, wasting of the muscle at the base of your thumb, or dropping things, come back sooner as that would indicate we need to act more quickly.' Follow-up in 6 to 8 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for carpal tunnel syndrome. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Median nerve distribution confirmed. Nocturnal pattern and flick sign identified. Contributing factors assessed (hypothyroidism, occupation). Severity assessed (thenar wasting, thumb weakness). Differentials considered (ulnar neuropathy, cervical radiculopathy).

Costs marks: Not localising to median nerve. Not asking about nocturnal pattern. Not checking thyroid. Not assessing for wasting.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Night splints prescribed. Thyroid review arranged. Ergonomic advice. Stepped pathway: conservative first, NCS if persistent, injection or surgery if severe. Correct safety netting for progression.

Costs marks: Jumping to surgery. No splints. Not reviewing thyroid. No follow-up plan.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing work concern (can she continue as a designer?). Explaining the condition in plain language. Providing reassurance about treatability. Practical advice she can start immediately.

Costs marks: Not addressing work impact. Using jargon. Being vague about prognosis.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not localising the symptoms to the median nerve distribution. If the little finger is numb, it is not carpal tunnel (ulnar nerve territory). Candidates must ask which specific fingers are affected.
  2. Not checking thyroid status. She has hypothyroidism. If undertreated, this can cause or worsen CTS. Candidates who diagnose CTS without checking TFTs miss a treatable contributing factor.
  3. Not assessing for thenar wasting. Advanced CTS with thenar wasting requires surgical referral, not conservative management. Candidates who prescribe splints without checking for muscle wasting may delay necessary surgery.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this carpal tunnel syndrome station?

Carpal tunnel stations test the candidate's ability to localise symptoms to the median nerve distribution and identify contributing factors. The pattern, nocturnal paraesthesia in thumb, index, middle, and radial ring finger, is highly specific. Mrs Crichton is 52, presenting with 3 months of bilateral hand numbness and tingling, worse at night, affecting her work as a graphic designer.

What does a strong performance look like to the examiner in this station?

Strong performances show: Median nerve distribution confirmed. Nocturnal pattern and flick sign identified. Contributing factors assessed (hypothyroidism, occupation). Severity assessed (thenar wasting, thumb weakness). Weak performances: Not localising to median nerve. Not asking about nocturnal pattern. Not checking thyroid. Not assessing for wasting.

What is the biggest pitfall in this carpal tunnel syndrome station?

Not localising the symptoms to the median nerve distribution. If the little finger is numb, it is not carpal tunnel (ulnar nerve territory). Candidates must ask which specific fingers are affected.

How should I prepare for carpal tunnel syndrome if I have never seen it in practice?

Structure beats experience here. Focus on nocturnal worsening and the flick sign as highly specific features of carpal tunnel syndrome. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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