What is the likely diagnosis for a 45-year-old female IDMT in the airforce with left wrist pain and numbness in her 4th and 5th fingers after push-ups and computer use, with positive nerve compression tests?

Clinical Note Assessment: Ulnar Tunnel Syndrome Documentation

Overall Assessment

Your clinical note demonstrates solid diagnostic reasoning and appropriate conservative management, but contains a critical diagnostic inconsistency that needs correction. The physical examination findings do not support your stated diagnosis of ulnar tunnel syndrome—in fact, they suggest carpal tunnel syndrome instead.

Critical Diagnostic Error

Your positive Phalen's and carpal tunnel compression tests are specific for carpal tunnel syndrome, not ulnar tunnel syndrome 1, 2. These provocative maneuvers compress the median nerve within the carpal tunnel, not the ulnar nerve in Guyon's canal 3, 4. The American College of Radiology emphasizes that carpal tunnel syndrome is primarily diagnosed through clinical evaluation, with key signs including characteristic sensory symptoms in the median nerve distribution and positive provocative tests 1.

What Your Exam Actually Shows:

• Positive Phalen's test = median nerve compression (carpal tunnel syndrome) 4
• Positive carpal tunnel compression test = median nerve compression (carpal tunnel syndrome) 4
• Numbness in 4th and 5th fingers = ulnar nerve distribution 5, 6
• TTP over ulnar tunnel = possible ulnar nerve involvement 5

You likely have a patient with coexisting carpal tunnel syndrome AND ulnar tunnel syndrome 5, 7. Studies show that silent ulnar neuropathy frequently coexists with symptomatic carpal tunnel syndrome, with abnormal median nerves being twice as likely to be symptomatic as abnormal ulnar nerves 7.

Specific Documentation Improvements Needed

1. Correct Your Diagnostic Statement

Replace: "Likely ulnar tunnel syndrome given history and physical exam. Considered carpal tunnel and arthritis."

With: "Likely coexisting carpal tunnel syndrome and ulnar tunnel syndrome. Positive Phalen's and carpal tunnel compression tests indicate median nerve involvement, while numbness in ulnar distribution (4th-5th fingers) and TTP over ulnar tunnel suggest concurrent ulnar nerve compression. Considered but less likely: isolated CTS with atypical sensory distribution, arthritis."

2. Add Missing Physical Exam Elements

Your exam is incomplete for proper nerve compression evaluation. You need to document 5, 6:

• Tinel's sign at the wrist (both carpal tunnel and Guyon's canal locations)
• Two-point discrimination testing in median (2nd-3rd fingers) vs ulnar (5th finger) distributions
• Intrinsic hand muscle strength (specifically first dorsal interosseous, abductor digiti minimi for ulnar motor function)
• Thenar eminence bulk (median motor function)
• Hypothenar eminence bulk (ulnar motor function)
• Froment's sign (ulnar nerve motor function)

3. Finkelstein's Test is Irrelevant Here

Remove the Finkelstein's test from your documentation—this tests for de Quervain's tenosynovitis (first dorsal compartment stenosing tenosynovitis), which is completely unrelated to nerve compression syndromes 8. Its inclusion suggests diagnostic confusion.

4. Management Plan Needs Modification

Your current plan of wrist brace alone is inadequate for dual nerve compression 2, 4. The American College of Physicians recommends that conservative management should include 2:

• Nighttime wrist splinting in neutral position (not just "wrist brace"—specify neutral positioning to avoid flexion/extension that worsens both conditions) 4
• Consider corticosteroid injection if symptoms persist beyond 2 weeks of splinting 2, 4
• Discontinue ineffective NSAIDs (which you appropriately did, as NSAIDs have limited efficacy for nerve compression) 2

5. Missing Critical Follow-Up Planning

You need electrodiagnostic studies if conservative management fails 1, 2, 3. The American Academy of Neurology recommends obtaining nerve conduction studies when surgical management is being considered, to determine severity and surgical prognosis 2. Given the complexity of dual nerve involvement, you should state: "If symptoms persist beyond 6 weeks of conservative treatment, refer for electrodiagnostic studies (nerve conduction studies and EMG) to quantify disease severity and localize compression sites prior to considering surgical decompression" 2, 4.

6. Add Red Flag Screening

Document that you screened for systemic causes, especially given bilateral symptoms are common and may indicate underlying conditions 1. You should note: "No clinical features suggesting diabetes, thyroid disease, rheumatoid arthritis, or amyloidosis. No bilateral symptoms to suggest systemic etiology" 1, 2.

Common Pitfalls You're Avoiding (Good Job)

• ✓ Appropriately declined NSAIDs (limited efficacy for nerve compression) 2
• ✓ Avoided premature surgical referral (conservative management should be attempted first for 6 weeks to 3 months in mild-moderate disease) 2, 4
• ✓ Provided activity modification counseling 4

Common Pitfalls You Need to Avoid Going Forward

• Don't proceed to surgery without attempting full conservative treatment (48-63% respond to conservative measures) 2
• Don't inject corticosteroids within 3 months of planned surgery if conservative treatment fails (increases infection risk) 2
• Don't ignore coexisting ulnar neuropathy when treating carpal tunnel syndrome—this is a frequent cause of persistent symptoms after carpal tunnel release 7
• Don't rely solely on clinical diagnosis for moderate-severe cases—electrodiagnostic studies resolve diagnostic uncertainty and quantify severity 3, 4

Revised Assessment and Plan (Suggested)

Assessment: Coexisting carpal tunnel syndrome and ulnar tunnel syndrome, left wrist. Positive Phalen's and carpal tunnel compression tests indicate median nerve compression. Numbness in ulnar nerve distribution (4th-5th fingers) with TTP over ulnar tunnel indicates concurrent ulnar nerve involvement at Guyon's canal. Symptoms precipitated by push-ups and aggravated by computer work. No evidence of systemic disease, arthritis, or tendinopathy.

Plan:

• Nighttime wrist splinting in neutral position, avoid wrist flexion/extension during activities 2, 4
• Activity modification: avoid push-ups and prolonged computer work; ergonomic keyboard positioning 4
• Patient declined NSAIDs (appropriate, as limited efficacy for nerve compression) 2
• Follow-up in 2 weeks: if no improvement, consider corticosteroid injection to carpal tunnel 2, 4
• If symptoms persist beyond 6 weeks of conservative treatment, refer for electrodiagnostic studies (NCS/EMG) to quantify severity and localize compression sites 2, 3, 4
• Return sooner if progressive weakness, thenar/hypothenar atrophy, or worsening numbness develops 4
• Patient verbalized understanding and agreement with plan