Ulnar Nerve Entrapment

Subjective: Patient presents with complaints of ulnar nerve entrapment symptoms, including intermittent numbness, tingling, and paresthesia in the fourth and fifth digits of the affected hand.  The patient reports the symptoms are worse at night and often awaken them from sleep.  They also describe occasional pain radiating up the medial forearm.  Symptoms are exacerbated by activities requiring sustained elbow flexion, such as driving or holding a phone.  The patient denies any recent trauma or injury to the elbow or wrist.  Past medical history includes type 2 diabetes mellitus and hypertension.  Current medications include metformin and lisinopril.  Social history is significant for a 20-pack-year smoking history.

Objective: Physical examination reveals positive Tinel's sign at the elbow and decreased sensation to light touch in the ulnar nerve distribution.  Muscle strength testing demonstrates mild weakness of the interossei and hypothenar muscles.  Wartenberg's sign is present.  Range of motion of the elbow and wrist is within normal limits, although the patient reports mild discomfort with elbow flexion beyond 90 degrees.  No edema or erythema is noted.  Electrodiagnostic studies, including nerve conduction velocity (NCV) and electromyography (EMG), are recommended to confirm the diagnosis and assess the severity of ulnar nerve compression.

Assessment:  Ulnar neuropathy at the elbow (cubital tunnel syndrome) is suspected, likely due to chronic compression of the ulnar nerve.  Differential diagnoses include ulnar nerve entrapment at the wrist (Guyon's canal syndrome), cervical radiculopathy, and peripheral neuropathy secondary to diabetes.  Further evaluation with electrodiagnostic testing will help differentiate these conditions.

Plan: Conservative management is recommended initially, including patient education on activity modification, avoiding prolonged elbow flexion, and using a padded elbow splint at night.  NSAIDs are prescribed for pain management.  Referral to occupational therapy for splinting and nerve gliding exercises will be initiated.  If symptoms do not improve within 4-6 weeks, or if electrodiagnostic studies reveal significant nerve compression, surgical intervention, such as ulnar nerve transposition or cubital tunnel release, will be considered.  Follow-up appointment scheduled in 4 weeks to assess response to treatment.  ICD-10 code G56.21, Ulnar nerve entrapment at elbow level, is assigned.