Dear Doctor
I have seen the above-named patient for several visits since her colonoscopy, and I wanted to update you about what has transpired. After the colonoscopy, I increased the Azulfidine to 2 q.i.d. I also sent stool for C. difficile, which was negative, and ordered an upper GI with a small bowel series. This showed a small sliding-type hiatal hernia with rapid transit time through the small bowel. The remainder of the examination was normal.
I saw this patient again 3 months later, at which time she had a fever and sweats with temperature of 103 degrees. I referred her to your office to further assess whether the Azulfidine or Crohn is the source of her fever. Also, when she took Lomotil for loose stools, she became obstipated. Metamucil may help avoid rebound constipation.
Thank you for allowing me to participate in this very lovely patient’s care and management.
Very truly yours,
Name.
FOOTNOTE
Line 13. Re was not dictated but was inserted to demonstrate proper format.
Line 20. C. difficile (Clostridium difficile).
Line 27. The apostrophe was removed even though dictated. Alternatively you can use the full term, i.e., Crohn disease.
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