Dear (blank),
Thank you very much for referring this 33-year-old male to me. He states he has had neck problems ever since he was a young child. As he has gotten older, they have gotten worse. He saw an orthopedist at one time who gave him a collar. He saw a chiropractor for about a year, which did help, but he could no longer financially afford it as he is not working at the present time. He has not seen the chiropractor for about a year.
The pain is mostly in the posterior aspect of the base of the skull and right side of the neck. Sometimes it gives him headaches. He has had no regular physical therapy. He has had some wrist pain in the past on the left side, which he said had some calcium deposits which were treated with a cast and a splint.
On examination, he has some tenderness on the right base of the skull along the right side of his neck. His range of motion is just about normal. Reflexes are intact.
X-rays of his neck, including flexion/extension films, show what appears to be an exostosis or osteoma at the base of the skull. This seems to be pretty much in the midline. I am not sure whether this is causing his problems. The disk space and foramen otherwise look completely normal.
We are going to start some regular physical therapy, and he will get back in touch with me as needed.
Again, thank you very much for referring this patient to me.
Sincerely yours,
Name.
FOOTNOTE
Line 13. Re was not dictated but was added to demonstrate proper letter format.
Line 22. Change them to it, referring to He saw a chiropractor in line 21.
Line 39. Alternative: Disc.
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