What is the diagnosis and treatment plan for a patient who presents with a history of two fractured fingers on the right hand, which occurred in 2015, two days prior to military discharge, and now experiences nerve pain, insomnia, and possible tinnitus (ringing in the ears), with symptoms of insomnia starting in 2009, and is seeking documentation for the Department of Veterans Affairs (VA)?

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Last updated: April 24, 2025 • View editorial policy

Differential Diagnosis

The patient presents with a history of traumatic injury to the right hand, specifically breaking two fingers in 2015, just before discharge from the military. The patient reports experiencing nerve pain when using the hand and also complains of insomnia, which was suggested to be related to tinnitus that started in 2009. Based on this information, the following differential diagnoses can be considered:

  • Single Most Likely Diagnosis + Malunion or Nonunion of Fractures: Given the patient's history of breaking two fingers and now experiencing pain and nerve symptoms, it is likely that the fractures did not heal properly, leading to malunion or nonunion. This would explain the ongoing pain and nerve symptoms.
  • Other Likely Diagnoses + Complex Regional Pain Syndrome (CRPS): The patient's report of nerve pain when using the hand could be indicative of CRPS, a condition characterized by chronic pain, inflammation, and hypersensitivity following an injury. + Tinnitus-related Insomnia: The patient's insomnia could be directly related to tinnitus, as suggested. Tinnitus can significantly impact sleep quality, leading to insomnia. + Post-Traumatic Stress Disorder (PTSD): Although not directly mentioned, the patient's military background and history of injury could predispose them to PTSD, which might contribute to insomnia and other symptoms.
  • Do Not Miss Diagnoses + Nerve Entrapment or Compression: Conditions like carpal tunnel syndrome or ulnar nerve entrapment could cause nerve pain and should not be missed, as they require specific treatment. + Osteoarthritis: Early onset osteoarthritis could be a consequence of the poorly healed fractures, leading to chronic pain and stiffness in the affected hand. + Sleep Apnea: While the patient mentions insomnia related to tinnitus, sleep apnea is a condition that should not be overlooked, as it can cause insomnia and is associated with significant morbidity if left untreated.
  • Rare Diagnoses + Sudeck's Atrophy: A rare condition that could follow a traumatic injury, characterized by chronic pain, swelling, and atrophy of the affected limb. + Neuroma: A benign growth of nerve tissue that could develop at the site of an injury, causing chronic pain and nerve symptoms.

Each of these diagnoses should be considered and investigated further with appropriate history, physical examination, and diagnostic tests to determine the underlying cause of the patient's symptoms.

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