DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of bilateral hand numbness and left forearm and wrist pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male who was seen in consultation for evaluation of bilateral hand numbness and left forearm and wrist pain. Over the past year or so, he has had intermittent numbness and tingling to both hands that has awoken him from sleep. This goes away after a brief period of time. However, recently, as of approximately two weeks ago, he had sudden and extreme pain into the left side. They woke him from sleep and then failed to improve for over 2 to 3 hours. This involves principally his long and ring finger. However, since making the appointment, the patient’s symptoms have markedly resolved, and currently, he has no disability or pain. The patient denies any numbness or tingling. He did wear a carpal tunnel-type splint at night about a week ago, and this dramatically helped his numbness and tingling. He has also reported some forearm tightness bilaterally, some left wrist pain, in addition to some thumb pain in the past. He is concerned about circulation into his hand, stating that he was swimming off of a beach last year, where he came out of the water with his hands numb and tingling, and this persisted for several hours. He reports having had some tingling in both feet. This is mainly after sitting in a strange position for a long period of time, and currently, this is not really symptomatic. The patient denies neck pain and denies any recent injury. As part of his job, he uses his hands and arms continuously in addition to using vibratory instruments.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: He has had prior left knee reconstruction.
MEDICATIONS: The patient takes amitriptyline.
ALLERGIES: He has no drug allergies.
SOCIAL HISTORY: The patient is married. The patient does not smoke and drinks occasionally.
PHYSICAL EXAMINATION: The patient is a very pleasant, articulate, healthy-appearing male, in no distress. His cervical neck motion is without pain. Elbow, hand, and wrist motion are full. He has positive Tinel’s over both carpal tunnels. Positive Tinel’s over both cubital tunnels. No tenderness over the pronator bilaterally. Markedly positive Tinel’s, just proximal to the transverse carpal ligament on the left wrist. No masses, warmth, or erythema noted. He has no pain with a resisted wrist flexion or wrist extension. No pain with resisted forearm pronation and supination. He is nontender over the medial or lateral epicondyle on either elbow. There is no evidence of ulnar nerve subluxation. A positive elbow flexion test under 30 seconds bilaterally. Positive Phalen’s maneuver, the left side 20 seconds, 30 seconds on the right. There is no evidence of thenar or hyperthenar atrophy. There is no intrinsic atrophy. Negative Wartenberg’s sign and negative Froment’s sign. No objective findings of decreased sensation. His hand is well perfused. He does not report having had any color changes with cold exposure or with any of his paresthesias. Motor strength is 5/5. Thumb is nontender. Wrist is nontender.
IMPRESSION AND PLAN: By history and partly clinical examination, his findings are consistent with cubital tunnel syndrome and carpal tunnel syndrome, left greater than right, and that is mild on both sides. Currently, he is minimally symptomatic. We discussed the pathophysiology of each. We have recommended nerve gliding exercises, extensor and flexor forearm stretching exercises. If his symptoms were to return simply, wrist braces at night or during the day such as driving can be helpful. Also discussed the role of cortisone injections if his symptoms were to worsen. Regarding his elbows, he will avoid leaning on the elbow or keeping it flexed for periods of time. If he developed further numbness into both hands or any involvement in his feet, we would recommend an EMG and nerve conduction studies and a probable neurology consultation to look for more intrinsic causes. At this point, he will follow up as needed given his relative lack of symptoms today. He is pleased with this disposition and will call if changes arise.
