ENT Case Study

To Whom It May Concern,

Michelle was first seen by me in February.  At that time she was complaining of vague symptoms.  She was under stress, but this was related to her work.  She also had a history of a kidney stone.

On examination at that time, she had red scaly patches under her ears, which subsequently turned out to be an allergy to her hair spray.  She had a left cervical posterior triangle node which was mobile and nontender, a scar over her right scapula where she had had a hemangioma at age 6 weeks, and bilateral mammary implants.

All the blood tests that were obtained were negative except for a low ferritin, related to her menstruating and her 2 pregnancies.  She was put on iron supplements.  She had a chest x-ray that was entirely normal.

She was seen again about a month later.  Her cervical node and axillary node had disappeared by then.  Because her nodes disappeared, she did not see a head and neck surgeon, and on examination today she certainly does not have these nodes.  A copy of her lab data is enclosed, and this was all essentially normal aside from the low ferritin.

In 1986, her blood pressure was 92/56 and she weighed
109-1/4 pounds.  Today her blood pressure is 106/60 and she weighs 111 pounds.  There has been no change in her blood pressure or her weight.

On examination today she still has the scar over her right shoulder blade.  I cannot today feel any axillary or cervical node enlargement whatever.  She still has the bilateral breast implants and a low C-section scar.  She tells me that she had a recent pelvic, Pap smear, and rectal examination by her gynecologist, and this was not done.  At the moment she is asymptomatic.  Indeed, she is only seeing me now because she is apparently having some trouble in getting medical insurance - this despite the fact that she has not seen a physician for any problems since last seeing me for a routine checkup.

I have ordered no routine or other blood studies at the time of this dictation.  She has had a recent Pap smear, is asymptomatic, is taking iron, and blood tests were essentially negative.  She has continued to feel good, not required medical care, and informs me that she has been in good health and seen no other physician during this time.

Sincerely yours,

Name.

FOOTNOTE

Line 9 (Page 1).  Re was not dictated but was added to demonstrate proper letter format.

Line 44 (Page 1).  Alternative:  Cesarean section.

Line 48 (Page 1).  The dictated period was changed to a dash.  A comma would also be acceptable.