Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with [acute/chronic] upper extremity dysfunction following [mechanism of injury, e.g., motorcycle accident/traction injury]. Reports [numbness/tingling/complete paralysis] in the [C5-T1] distribution. Onset of symptoms: [Date/Time]. Associated symptoms include [atrophy/pain/loss of sensation]. Previous interventions: [None/PT/Surgical exploration].
Clinical Examination Findings
Physical exam reveals [atrophy/fasciculations] of the [deltoid/biceps/triceps/intrinsic hand muscles]. Motor strength graded [0-5/5] per MRC scale. Sensory deficit noted in [dermatomal distribution]. Reflexes: [Biceps/Brachioradialis/Triceps] are [absent/diminished]. Tinelโs sign [positive/negative] along the supraclavicular fossa. Range of motion limited in [shoulder/elbow/wrist].
Treatment Protocol
Recommended management plan: [Conservative/Surgical]. If surgical: [Nerve graft/Nerve transfer/Tendon transfer/Neurolysis]. Post-operative plan includes [immobilization/early range of motion/intensive physical therapy]. Pain management: [Neuropathic agents/Analgesics]. Follow-up scheduled in [weeks/months] for reassessment of nerve regeneration.