Presenting Complaints:
A 45-year-old male presents with complaints of numbness and tingling in the ring and little fingers of his right hand. He reports that these symptoms have been present for the past six months and have gradually worsened over time. He also mentions occasional weakness and clumsiness in his right hand, particularly while gripping objects or performing repetitive tasks.
History of Presenting Complaints:
The patient states that his symptoms initially appeared after a period of prolonged computer use at work. He recalls experiencing discomfort and aching in his right elbow during that time. He did not seek medical attention initially, hoping the symptoms would resolve on their own. However, as the numbness and weakness persisted and interfered with his daily activities, he decided to seek medical advice.
Chief Complaints:
Numbness and tingling in the ring and little fingers of the right hand.
Weakness and clumsiness in the right hand, especially during gripping and repetitive tasks.
Past Medical and Surgical History:
The patient has no significant past medical or surgical history. He has never experienced similar symptoms in the past.
Family History:
There is no family history of similar symptoms or any hereditary conditions related to the musculoskeletal system.
Socioeconomic Status:
The patient is employed full-time in an office job and has medical insurance coverage.
Present and Pre-Morbid Functional Status:
Prior to the onset of symptoms, the patient had no functional limitations. He was able to perform all activities of daily living without any difficulty.
General Health Status:
The patient reports good general health and denies any other significant medical conditions. He is a non-smoker and does not consume alcohol excessively.
Vitals:
Blood pressure: 120/80 mmHg
Heart rate: 72 bpm
Respiratory rate: 14 breaths per minute
Temperature: 98.6°F (37°C)
Aggravating Factors:
The patient reports that his symptoms worsen with activities that involve prolonged bending or flexing of the elbow, such as using a computer mouse, driving, or talking on the phone for an extended period.
Easing Factors:
The symptoms tend to improve when the patient changes his arm position, shakes his hand, or takes short breaks from repetitive activities.
Examination:
Inspection of the right elbow reveals no visible deformities or swelling.
Palpation elicits tenderness over the cubital tunnel.
Sensory examination demonstrates decreased two-point discrimination in the ulnar nerve distribution (ring and little fingers).
Motor examination reveals mild weakness in the muscles innervated by the ulnar nerve, particularly the intrinsic hand muscles.
Tinel’s sign is positive over the cubital tunnel.
Phalen’s test and Reverse Phalen’s test are negative.
Sleep and 24-hour Pattern:
The patient reports disturbed sleep due to intermittent numbness and tingling in his hand, which wakes him up at night. He notices that symptoms tend to be worse in the morning and gradually improve throughout the day.
Duration of Current Symptoms:
The patient has been experiencing symptoms for the past six months, which have progressively worsened over time.
Mechanism of Injury/Current Symptoms:
The patient attributes his symptoms to prolonged elbow flexion and pressure on the ulnar nerve during computer use. He reports frequent resting of his right elbow on the edge of his desk while typing, which may have contributed to nerve compression.
Progression Since the Current Episode:
The patient reports a gradual increase in the intensity and frequency of his symptoms since the onset. Initially, he experienced intermittent numbness and tingling, but now it is persistent, affecting his daily activities.
Significant Prior History:
There is no significant prior history of trauma, infections, or other medical conditions related to the upper extremities.
Previous Treatment:
The patient has not received any prior treatment for his symptoms. He tried over-the-counter pain medications, but they provided only temporary relief.
Diagnostic Test/Imaging:
Nerve conduction studies and electromyography (EMG) reveal evidence of ulnar nerve compression at the cubital tunnel.
X-rays of the right elbow are normal, ruling out bony abnormalities or fractures.
Differential Diagnosis:
Cubital tunnel syndrome
Cervical radiculopathy affecting the C8 nerve root
Ulnar nerve entrapment at other sites (e.g., Guyon’s canal)
Peripheral neuropathy
Brachial plexopathy
Postural Observation:
No significant abnormalities observed during postural observation.
Precaution and Contraindications:
Avoid prolonged elbow flexion and resting the elbow on hard surfaces.
Minimize repetitive gripping and activities that exacerbate symptoms.
Avoid pressure on the cubital tunnel during sleep by using a splint or cushioning the elbow.
Functional Movement Analysis (Sign):
The patient demonstrates difficulty with fine motor tasks requiring precise finger movements, such as buttoning shirts or picking up small objects.
Quick Screening Tests/Clearing of Additional Joint Structures:
Range of Motion (ROM):
Active and passive range of motion of the right elbow, wrist, and fingers is within normal limits.
No significant limitations or pain reported during ROM testing.
Special Tests:
Tinel’s sign over the cubital tunnel is positive, eliciting a tingling sensation down the ulnar nerve distribution.
Froment’s sign is positive, indicating weakness of the adductor pollicis muscle during a pinch grip test.
Assessment:
Based on the patient’s history, clinical examination findings, and diagnostic tests, the assessment is cubital tunnel syndrome (compression of the ulnar nerve at the cubital tunnel).
Problem List/Complaints:
Numbness and tingling in the ring and little fingers of the right hand.
Weakness and clumsiness in the right hand, particularly during gripping and repetitive tasks.
Treatment:
Conservative management: The patient will be advised to modify activities to minimize pressure on the cubital tunnel. He will be instructed to avoid prolonged elbow flexion and repetitive gripping. The use of a splint at night to prevent compression during sleep will be recommended.
Physical therapy: The patient will be referred for physical therapy sessions focusing on nerve gliding exercises, stretching, and strengthening exercises for the forearm and hand muscles.
Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to alleviate pain and inflammation.
Prognosis:
With appropriate management, including activity modification and physical therapy, the prognosis for cubital tunnel syndrome is generally favorable. Symptoms often improve over time, although complete resolution may take several months.
Goals:
Reduce numbness and tingling in the ring and little fingers.
Improve hand strength and coordination.
Minimize pain and discomfort associated with cubital tunnel syndrome.
Interventions:
Patient education on activity modification, ergonomic principles, and strategies to relieve pressure on the cubital tunnel.
Referral to physical therapy for targeted exercises and stretches.
Medication management to alleviate pain and inflammation, if necessary.
Patient Education:
The patient will be educated on the following topics:
Cubital tunnel syndrome: Causes, symptoms, and risk factors.
Activity modification: Techniques to avoid excessive pressure on the ulnar nerve.
Ergonomics: Proper workstation setup and posture to reduce strain on the elbow.
Home exercises: Nerve gliding exercises, stretching, and strengthening exercises.
Importance of compliance with treatment and follow-up appointments.
Patient/Family Education:
The patient’s family members will be educated on the following:
Supportive measures to assist the patient in minimizing pressure on the affected arm.
Encouragement for compliance with activity modification and home exercise programs.
Recognition of warning signs or worsening symptoms requiring prompt medical evaluation.
Discharge Plan:
Follow-up appointment with the physician in two weeks to assess treatment response.
Referral to physical therapy for ongoing rehabilitation.
Contact information provided for any questions, concerns, or if symptoms worsen before the next appointment.