New Patient Letter

Dear Mr Smith, Diagnosis: Carpal Tunnel Syndrome Problem: Numbness and tingling in the right hand, particularly affecting the thumb, index, and middle fingers. Plan: We will proceed with a carpal tunnel release surgery to alleviate the symptoms. This will be an outpatient procedure with local anaesthesia. Thank you for coming to see me today. Your main concern was the persistent numbness and tingling in your right hand, which has been affecting your daily activities and work as a graphic designer. Your past medical history includes hypertension, and you are right-hand dominant. You are 45 years old and work as a graphic designer. You have a history of smoking 5 cigarettes a day and consume alcohol socially. Examination findings revealed positive Tinel's and Phalen's signs in the right hand. Investigations planned include an electromyography (EMG) to assess the severity of the nerve compression. The condition is explained as compression of the median nerve at the wrist, and treatment options include surgical release or conservative management with wrist splints and physiotherapy. Non-surgical treatment options include wrist splints and physiotherapy, but given the severity, surgery is recommended. Surgical treatment planned involves a carpal tunnel release, expected to relieve symptoms with minimal risks. The procedure will be outpatient, and fixation is not required. Pre-operative preparation includes stopping smoking and avoiding alcohol a week before surgery. Post-operative care plan involves a short hospital stay, followed by physiotherapy to regain hand function, pain management with analgesics, and a follow-up appointment in two weeks. Additional advice includes joining a support group for individuals with similar conditions and accessing educational materials on hand care post-surgery. Relevant referrals include physiotherapy for post-operative rehabilitation. I look forward to seeing you on the day of surgery. Best wishes, Dr. Thomas Kelly