Follow Up Letter

ACC#: 123456 Date of Injury: 15 October 2024 Diagnosis: 1) Fracture of the right scaphoid 2) Carpal tunnel syndrome John Doe was reviewed at 6 weeks following open reduction and internal fixation of the right scaphoid fracture performed on 20 September 2024. Recent X-rays show satisfactory alignment and early signs of bone healing without any displacement. The patient reports persistent numbness and tingling in the right hand, particularly affecting the thumb and index finger, which worsens at night. Examination reveals: - Limited range of motion in the right wrist - Mild swelling around the surgical site - Tenderness over the scaphoid - Positive Tinel's sign at the wrist Overall, the clinical assessment indicates good progress in fracture healing, but ongoing symptoms of carpal tunnel syndrome require further management. Treatment plan includes: - Continued use of a wrist splint - Referral to hand therapy for range of motion exercises - Prescription of NSAIDs for pain management - Follow-up imaging in 4 weeks He will be reviewed in 4 weeks to reassess progress and discuss potential surgical intervention for carpal tunnel syndrome if symptoms persist.