After Visit Letter

Dear Eleanor Vance

Thank you for attending our clinic today. The following summarises your visit and the next steps in your care.

14/10/2023

Reason for Visit

• OT evaluation for B hand pain, stiffness, and decreased grip strength x 6 mos. Reports difficulty with IADLs/ADLs, specifically opening jars, buttoning clothes, and meal prep.

Findings

• Mild edema and tenderness at B 1st CMC and PIP joints.
• Jamar dynamometer grip strength: R 12 kg, L 10 kg. Lateral pinch: R 3.5 kg, L 3 kg.
• AROM within functional limits except B thumb opposition (short of 5th MCP by 1 cm).

Diagnosis

• Bilateral primary osteoarthritis of the first carpometacarpal joints, with resulting ADL/IADL deficits.

Treatment Plan

• Fitted with custom B thumb spica orthoses; wear during heavy grip activities and overnight.
• Instructed in joint protection techniques, energy conservation, and adaptive equipment use (built-up utensils, jar opener).
• Provided HEP for gentle AROM/tendon gliding exercises 2x/day; use paraffin bath or warm water soaks prior to exercises for stiffness.
• Continue current analgesic regimen as prescribed by PCP.

Medications

• diclofenac sodium (Voltaren®) 1 % topical gel QID PRN
• paracetamol (acetaminophen, Tylenol®) 500 mg PO TID PRN
• turmeric extract 500 mg PO daily

Allergies

• Penicillin (rash)

Next Appointment

• 28/10/2023 at 10:30 MST

Additional Notes

• Monitor skin daily for redness or pressure areas from the new splints. Discontinue splint wear and contact the clinic if numbness, tingling, or increased pain occurs.

If you have questions or concerns, please contact our office.

Sincerely, Sarah Jenkins, OTR/L, CHT Rocky Mountain Hand Therapy, 303-555-0192, s.jenkins@rmhandtherapy.org