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Dr. Marmick 9

The letter refers Ms. Betty Weston, a 54-year-old supermarket manager, to an occupational therapist for assessment of possible carpal tunnel syndrome and ergonomic evaluation. Ms. Weston presents with numbness and pain in her right hand relieved by movement. Examination found positive Phalen's and Tinel's signs with reduced grip strength, consistent with carpal tunnel syndrome. She was prescribed paracetamol and advised to wear a wrist splint and see a physiotherapist for exercise and weight loss management.

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189 views2 pages

Dr. Marmick 9

The letter refers Ms. Betty Weston, a 54-year-old supermarket manager, to an occupational therapist for assessment of possible carpal tunnel syndrome and ergonomic evaluation. Ms. Weston presents with numbness and pain in her right hand relieved by movement. Examination found positive Phalen's and Tinel's signs with reduced grip strength, consistent with carpal tunnel syndrome. She was prescribed paracetamol and advised to wear a wrist splint and see a physiotherapist for exercise and weight loss management.

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MASONEJI
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We take content rights seriously. If you suspect this is your content, claim it here.
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You are on page 1/ 2

Ms.

Alison Goody

Occupational Therapist

Northwood Community Health Centre

Northwood

17/06/2018

Dear Ms. Goody

Re: Ms. Betty Weston; D.O.B.: 12/02/1964

I am writing to refer Ms. Weston, a 54-year-old supermarket manager, whose clinical features are
consistent with carpal tunnel syndrome. Your further management and ergonomics assessment
would be appreciated.

Ms. Weston's medical history is significant for obesity (BMI 32), type 2 diabetes, hypothyroidism,
and arthrosis. She leads a sedentary lifestyle and has poor diet control. She does not smoke or
drink.

1. Obesity, poor diet, and sedentary lifestyle are related and could have been one sentence—
Ms Weston is obese with poor dietary habits, and leads a sedentary lifestyle
2. On today’s visit, her BMI has decreased, so you shouldn’t put the value of BMI in there as
she no longer has that BMI.

On June 10, Miss Weston first presented complaining of for complaints of paresthesia and
associated pain over the thumb, middle, and index fingers of the right hand, which was often
relieved by movement. During examination, Phalen’s maneuver and Tinel’s sign were noted as
positive, along with and there was a diminished grip strength. However, all her other examinations
were unremarkable; therefore, the aforementioned diagnosis was established. Consequently, She
was prescribed a 500mg paracetamol tablet and administered conservative treatment for her co-
morbidities was continued.
1. Name the diagnosis rather than writing ‘aforementioned diagnosis’
2. Don’t use the word “administered” for oral medications.

Upon review today, Ms. Weston is ready for discharge, although she appears to be fatigued.
Subsequently, She was advised to wear a wrist splint at night for at least three weeks, and a referral
to a physiotherapist for exercise and weight loss management was recommended.

1. Ready for discharge??? There is no hospital admission


2. You didn’t cover all the complaints—those were of hypothyroidism, a condition which is
associated with carpel tunnel syndrome
3. Nerve conduction studies were done as well to assess the severity and exclude other
diagnosis—you didn’t mention that
4. In the first sentence, there is present tense and in the next sentence, you have used past
tense.
5. Messed this visit up completely.

In light of the above, you are requested to ensure assist Ms. Weston has with a customized wrist
splint placed at neutral position, along with an assessment of her ergonomics. Your further
contribution assistance in managing her condition would be immensely valued.

1. Along with an assessment of her erogonomics—doesn’t make any sense—erogonomics


assessment (there is not alternative for this phrase)

If you require any additional information, please do not hesitate to contact me.

Yours sincerely

Doctor

Remarks:
The purpose is clear and everything was fine minus today’s visit. On today’s visit, you have messed up
the content and clarity. You have a tendency to use some words inappropriately, and there were a few
grammatical issues as well.

Estimated Grade: B/370

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