OB-GYN Study

LETTER

Date

Name

Address

City, State, Zip

Gentlemen,

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

History

This 42-year-old woman was seen in consultation regarding problems referable to her right and left breasts.  This patient has a long history of bilateral fibrocystic disease with episodes of mastitis in both breasts.  The patient underwent a bilateral subcutaneous mastectomy with implant reconstruction.  Subsequently, because of complications with contractures, these implants were removed.  The patient developed a lump in her right breast, which was diagnosed as a probable recurrent cyst near the axilla.  This was followed for almost 1 year without change.  However, the lump became somewhat tender.  Examination revealed some ill-defined induration in the upper outer quadrant of the right breast flap.  Old incisional scars were noted in both breasts.

Diagnoses

1. Probable residual fibrocystic disease in the upper outer quadrant of the right breast.

2. Status postoperative bilateral subcutaneous mastectomy.

Comments

1. The patient is seeking consultation both in regard to the induration in the upper outer quadrant of the right breast as well as for possible reconstructive surgery to both breasts.  She has never fully accepted the resection of the breast tissue and the loss of the implant reconstruction.

2. I have suggested to the patient that we could consider at this point in time removal of the area of induration from the upper outer quadrant of the right breast which is so tender, as well as performing an implant reconstruction of the right and left breasts using polyurethane-type implants.

3. The patient would appreciate a letter stating that this would be covered under her group health insurance program.

4. I have included a copy of the pathology report from the tissue resected.

Sincerely,

Name.

FOOTNOTE

Lines 18, 33, 38 (Page 1).  It is not necessary to type headings in all capitals in a letter, but it is acceptable to do so.