Patient Information:
Name: John Smith
Age: 42
Gender: Male
Occupation: Software Engineer
Presenting Complaints:
John Smith presented to the clinic with complaints of weakness and numbness in his left hand and fingers. He reported difficulty in gripping objects, especially small ones like pens, and occasional clumsiness while performing fine motor tasks.
History of Presenting Complaints:
John mentioned that he had first noticed these symptoms about six months ago. The weakness and numbness initially started as occasional tingling in the ulnar aspect of his left hand, particularly the fourth and fifth fingers. Over time, these sensations progressed to muscle weakness, making tasks like typing, writing, and buttoning shirts increasingly challenging.
Chief Complaints:
Weakness in left hand, particularly in the fourth and fifth fingers.
Numbness and tingling in the ulnar aspect of the left hand.
Past Medical and Surgical History:
John’s medical history was unremarkable, with no chronic medical conditions or prior surgeries. He had no history of trauma or injuries to his left arm.
Family History:
There was no significant family history of neurological disorders or similar symptoms.
Socioeconomic Status:
John belonged to a middle-income socioeconomic status.
Present and Pre-morbid Functional Status:
Prior to the onset of symptoms, John had full functional capacity and was able to perform his work and daily activities without any issues.
General Health Status:
Overall, John was in good general health with no significant medical concerns.
Vitals:
Blood Pressure: 120/80 mmHg
Heart Rate: 72 bpm
Respiratory Rate: 16 bpm
Temperature: 98.6°F (37°C)
Aggravating Factors:
The symptoms worsened when John performed repetitive activities involving wrist flexion and extension, such as prolonged typing or using a computer mouse.
Easing Factors:
Resting his left hand and avoiding activities that involved prolonged wrist movements provided temporary relief from the symptoms.
Examination:
Sensory examination revealed decreased sensation in the ulnar distribution of the left hand.
Motor examination showed weakness in the hypothenar muscles and the interossei of the left hand.
Tinel’s sign was positive, eliciting tingling sensations when tapping over the ulnar nerve at the elbow.
Froment’s sign was positive, indicating compensatory thumb flexion during pinch grip due to adductor pollicis weakness.
Sleep and 24-hour Pattern:
John reported that his symptoms were relatively constant throughout the day and did not notably worsen during the night.
Duration of Current Symptoms:
Approximately six months.
Mechanism of Injury/Current Symptoms:
The symptoms appeared to be related to nerve compression or entrapment, possibly at the level of the ulnar nerve at the elbow (cubital tunnel syndrome).
Progression Since the Current Episode:
The symptoms had gradually worsened since their onset, affecting John’s ability to perform his job and daily tasks.
Significant Prior History:
There was no significant prior history of similar symptoms or injuries.
Previous Treatment:
John had tried conservative measures such as rest, ergonomic adjustments to his workspace, and over-the-counter pain relievers, but these measures provided only temporary relief.
Diagnostic Test/Imaging:
An electromyography (EMG) and nerve conduction study (NCS) were conducted, confirming ulnar nerve entrapment at the elbow.
Differential Diagnosis:
Cubital tunnel syndrome
Thoracic outlet syndrome
Cervical radiculopathy
Brachial plexus injury
Postural Observation:
John exhibited a slightly flexed posture of the left elbow during rest.
Precaution and Contraindications:
John was advised to avoid activities that involved prolonged elbow flexion and compression of the ulnar nerve.
Functional Movement Analysis (Sign):
Froment’s sign (positive) – Compensation of thumb flexion during pinch grip due to adductor pollicis weakness.
Quick Screening Tests/Clearing of Additional Joint Structures:
Tinel’s sign (positive) – Tingling sensations elicited when tapping over the ulnar nerve at the elbow.
Range of Motion (ROM):
John had full range of motion in the left wrist and fingers without pain.
Special Tests:
EMG/NCS – Confirmed ulnar nerve entrapment at the elbow.
Tinel’s sign – Positive for ulnar nerve irritation at the elbow.
Froment’s sign – Positive for ulnar nerve motor weakness.
Assessment:
Tardy ulnar nerve palsy (cubital tunnel syndrome) resulting in sensory and motor deficits in the ulnar distribution of the left hand.
Problem List/Complaints:
Weakness in the fourth and fifth fingers of the left hand.
Numbness and tingling in the ulnar aspect of the left hand.
Difficulty with fine motor tasks.
Treatment:
Rest and activity modification.
Physical therapy for nerve gliding exercises and strengthening.
Elbow padding to minimize nerve compression.
Possible referral to a specialist for surgical evaluation if conservative treatment is ineffective.
Prognosis:
With appropriate treatment and activity modification, John’s symptoms are likely to improve. The prognosis may vary depending on the severity of nerve compression and his response to treatment.
Goals:
Reduce numbness and tingling in the ulnar aspect of the left hand.
Improve strength and functional use of the fourth and fifth fingers.
Enable John to resume normal work and daily activities without limitations.
Interventions:
Physical therapy with nerve gliding exercises and ulnar nerve flossing.
Ergonomic adjustments to workspace to minimize elbow flexion.
Use of padding to alleviate pressure on the ulnar nerve.
NSAIDs or pain relievers for symptomatic relief.
Patient Education:
John was educated about the condition, the importance of activity modification, and the exercises prescribed. He was advised to avoid activities that aggravated his symptoms and to follow through with the recommended treatment plan.
Patient/Family Education:
John’s family was educated about his condition, treatment plan, and the need for support during his recovery process.
Discharge Plan:
Follow up with physical therapist for regular sessions.
Monitor symptoms and report any changes or worsening.
Return to the clinic for a follow-up evaluation to assess progress and adjust the treatment plan if necessary.