Subjective: Patient presents with complaints of ulnar nerve symptoms including numbness, tingling, andor pain in the fourth and fifth digits, potentially radiating up the forearm.  Onset of symptoms is described as gradualprogressiveintermittent, with exacerbating factors such as elbow flexion, prolonged pressure on the elbow, or repetitive hand movements.  Patient reports difficulty with fine motor skills, grip weakness, andor clumsiness.  Symptoms interfere with activities of daily living such as writing, typing, and buttoning clothes.  Past medical history includes diabetes mellitushypertensionhypothyroidism, and no prior history of ulnar nerve compression or injury.  Social history includes occupation as a construction workerdentistoffice worker, with frequent repetitive hand and arm movements.

Objective: Physical examination reveals positive Tinel's sign at the elbow andor Guyon's canal.  Sensory examination demonstrates decreased sensation to light touch and pinprick in the ulnar nerve distribution.  Motor examination reveals weakness of the interosseous muscles, with possible clawing of the fourth and fifth digits.  Froment's sign may be present.  Electrodiagnostic studies, including nerve conduction velocity (NCV) and electromyography (EMG), were ordered to assess ulnar nerve function and confirm the diagnosis of ulnar neuropathycubital tunnel syndromeGuyon's canal syndrome.  Differential diagnoses considered include cervical radiculopathy, brachial plexopathy, and other peripheral neuropathies.

Assessment:  Based on the patient's symptoms, physical examination findings, and plannedor completed electrodiagnostic studies, the diagnosis of ulnar neuropathy is established.  The location of compression is suspected to be at the elbow (cubital tunnel syndrome) or wrist (Guyon's canal syndrome), pending electrodiagnostic study results.  Severity is classified as mildmoderate or severe based on the degree of sensory and motor deficits.  ICD-10 code G56.2 (other entrapment neuropathies) or G56.3 (other mononeuropathies of upper limb) is documented as well as appropriate CPT billing codes for the evaluation and management services provided and any procedures performed.

Plan:  Conservative treatment is recommended initially, including activity modification, avoidance of aggravating factors, elbow splinting (especially at night), and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management.  Patient education regarding proper ergonomics and postural adjustments is provided.  Referral to occupational therapy for hand strengthening and fine motor skill exercises is considered.  If symptoms persist or worsen despite conservative measures, surgical intervention, such as ulnar nerve decompression or transposition, may be indicated.  Follow-up appointment is scheduled in 4-6 weeks to reassess symptoms and discuss further management options.  Patient is advised to return sooner if symptoms worsen or new symptoms develop.