Cubital Tunnel Syndrome Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 45y/oRHD male c/o pain and parathesias in the small and ring finger gradually worsening over several months. Occasional 3-7/10 lateral elbow pain. Worse with activity such as coming hair and drving. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Skin / Lymph: normal, no scars
Tenderness: along ulnar nerve in cubital tunnel
No hypthenar wasting, No clawing.
Normal sensation in dorsal wrist/hand
ROM (R/L): 0-135 / 0-135
Ulnar nerve remains in groove
Suppination (R/L): 80 / 80
Pronation (R/L): 80 / 80
Positive Tinel's at the Cubital tunnel
Symptoms reproduced with elbow maximally flexed and wrist extended
Normal Froments sign
Normal Jeanne's sign
Subjective normal M/U/R distal sensation
2+ Radial pulse
Xray: no osseous deformity, no UCL calcifications or arthritis
MRI: none
ASSESSMENT: Cubital Tunnel Syndrome (354.2)
We discussed the natural history and both operative and non-operative treatment options. We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment. All questions were answered. Available links to further peer-reviewed written information on the diagnosis were provided. We discussed surgcial risks including but not limited to: incomplete relief of pain, incomplete return of function, posterior numbess, painful neuroma, CRPS, stiffness, continued symptoms (paresthesias, weakness, pain) and the risks of anesthesia includining heart attack, stroke and death. We will begin treatment with activity modifications, night extension splinting, and NSAIDS. An EMG was also ordered for further evaluation. He will follow-up after the EMG for continued evaluation and management.