ENT Case Study

At the request of my patient, I am forwarding this brief medical report.

History

The patient, a 24-year-old woman, was seen in consultation regarding problems referable to her nasal breathing.  The patient complains of progressive congestion, a pressure sensation within the nose, sniffing, and stuffiness.  In addition, she has had episodes of sneezing, itching, and watery eyes.  She has more problems breathing through the right side of the nose than the left.

Examination

Examination reveals the nasal septum to have somewhat of an
S-shaped configuration with the midsection curved to the right of the midline and the caudal edge of the quadrilateral cartilage to the left of the midline.  There is marked obstruction of the right nasal passage.  She has some asymmetry to the dorsal nose as well.

Diagnoses

1. Inadequate nasal airway.

2. Deviated nasal septum.

3. Possible rhinitis.

Comments

1. I have discussed with the patient the treatment of this condition with a nasal septoplasty with partial submucous resection.

2. In addition, simultaneously a modified rhinoplasty would be performed.

3. The patient would appreciate a letter from Blue Cross stating that these treatments would be covered on her group health insurance program.

4. The surgery would be performed in an office setting and would not require any hospitalization.

Sincerely,

Name.

FOOTNOTE

Line 13 (Page 1).  Re was not dictated but was added to demonstrate proper letter format.

Lines 37-40 (Page 1).  The physician dictated the numeral 1 but failed to enumerate the remaining diagnoses, dictating commas to separate the diagnoses.  Add the remaining numerals.