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Difficulty: MediumPhysical Examination Findings

A 4545-year-old woman is evaluated during morning rounds on post-operative day two following a total thyroidectomy for a multinodular goiter. She complains of a new-onset "pins and needles" sensation around her mouth and in both hands. Her temperature is 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), blood pressure is 122/78122/78 mm Hg, and pulse is 8484/min. The physician suspects a specific electrolyte abnormality and decides to perform a diagnostic physical examination maneuver by inflating a blood pressure cuff on her arm to 2020 mm Hg above her systolic pressure for three minutes. Which of the following physical examination findings is most likely to be observed in this patient?

  1. Flexion of the wrist and metacarpophalangeal joints with extension of the interphalangeal jointsAnswer
  2. B
    Twitching of the ipsilateral facial muscles, particularly around the upper lip and eye
  3. C
    Development of a petechial rash on the forearm and hand distal to the inflated cuff
  4. D
    Paresthesias radiating specifically into the palmar surface of the thumb, index, and middle fingers
  5. E
    A downward drift and pronation of the affected arm when extended with palms facing upward

Answer

Flexion of the wrist and metacarpophalangeal joints with extension of the interphalangeal joints
The patient's presentation of perioral and acral paresthesias following a total thyroidectomy is highly suspicious for acute hypocalcemia due to transient or permanent hypoparathyroidism. The physician is performing the maneuver to elicit Trousseau sign of latent tetany. Inflation of a sphygmomanometer above the systolic blood pressure for three minutes causes localized ischemia, which further increases the neuromuscular irritability already present from the low calcium levels. A positive Trousseau sign is characterized by carpal spasm, which manifests as flexion of the wrist and metacarpophalangeal joints, accompanied by extension of the interphalangeal joints and adduction of the thumb. Trousseau sign is generally considered more sensitive and specific for hypocalcemia than Chvostek sign.

Step-by-Step Solution

1
Analyze the clinical presentation and surgical history.
The patient has perioral and acral paresthesias two days after a total thyroidectomy.
These are classic symptoms of acute hypocalcemia, which commonly occurs post-thyroidectomy due to inadvertent injury or removal of the parathyroid glands.
2
Identify the physical examination maneuver being performed.
Inflating a blood pressure cuff above systolic pressure for three minutes is the specific maneuver used to elicit Trousseau sign.
This maneuver induces localized ischemia, which exacerbates the neuromuscular excitability caused by hypocalcemia.
3
Correlate the maneuver with the expected physical finding.
The expected finding is carpal spasm.
Carpal spasm presents physically as flexion of the wrist and metacarpophalangeal joints, extension of the interphalangeal joints, and adduction of the thumb.

Key Concept

Physical examination signs of acute hypocalcemia (Trousseau sign)
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Topics

Physical Examination Findings

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