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GENERAL SURGERY
Dr. Jane Smith, FRCSC, FACS General Surgeon
123-456-7890
______________________________________________________________________________________________________________
123 Main Street, Suite 101
Anywhere, Ontario A1A 1A1
January 1, 2023
Dr. Random Name
Address 1, Address 2
Anywhere, ON B2B 2B2
RE: DOE, Jane A.
Dear Dr. Name,
Thank you for asking me to see this 55-year-old woman with right upper quadrant pain. She has had it for many months now. She describes it as occurring in the evening. It is not related to meals. She works nights as a cleaner and finds that when she mops the floor or twists, she gets sharp pain. It can last anywhere from a couple of hours to longer. There are no GI symptoms. She has not had fever or jaundice. The pain doesn’t radiate. It typically is not there when she is not working.
There is no change in her bowels or urinary function and overall, she is well. There is no family history of gallstones.
She takes Diamicron, Coversyl, Janumet and Crestor and Jardiance.
She has diabetes, hypertension and high cholesterol. She doesn’t smoke.
Jane was examined. She has a soft abdomen. She was a little tender high in the right upper quadrant on deep inspiration. There were no masses or other findings. She was not tender over her chest wall.
Thank you for forwarding her abdominal ultrasound which did confirm multiple gallstones. The biliary tree was normal.
Even though she does have gallstones I am not convinced that that is the cause of her symptoms. Her pain, to me, sounds more musculoskeletal. She does have a couple of days off work over the holidays that I have suggested that she apply some heat, massage the area and use some anti-inflammatory and see if this will alleviate the discomfort. Should she develop any symptoms that are more in keeping with biliary colic such as postprandial pain, GI upset etc. I would be happy to reevaluate her. Thank you kindly.
Regards,
Dr. Jane Smith, FRCSC, FACS
(Dictated but not read)
JS/pmts
GASTROENTEROLOGY
John W. Doe MD, FRCPC
Gastroenterology, Hepatology and Internal Medicine
Medical Centre
000 Some Street,
Unit 00
Anywhere, ON P9P 9P9
(123)456/7890
Fax (098)765-4321
October 12, 2023
Dr. XXXXX XXXXXX
Fax: 000-000-0000
RE: Last, First
DOB: January 1, 1980
Dear Dr. XXXXXXX,
Thank you for your kind referral. As you know, this is a 44-year-old gentleman referred for hyperferritinemia. He denies any symptoms related to chronic liver disease and there is no history of hepatitis. In general he is in good health and feels well – this was noted on routine blood work. There is no family history of chronic liver disease.
Past Medical History: he has no significant past medical history
Medications: None
Allergies: None
Family History: positive only for coronary artery disease
Social History: no tobacco. He has moderate alcohol use, drinks about a beer a day but sometimes more and he wondered, in retrospect, towards the end of the interview if maybe he drinks more than he readily admits. He is single with no children and works as a technician.
On exam he is awake, alert and oriented
Chest: clear
CV: normal heart sounds, no murmurs noted
Abd: soft, non-tender, no mass palpable, no obvious enlargement of the liver or spleen. No stigmata of chronic liver disease
Ext: grossly normal
Labs: He had a ferritin of 402 on May 30th. In January 2009 his iron saturation was 18 % with an iron level of 10. Hgb 150, MCV 89, platelets 173, glucose 5.1, creatinine 91, ALT 33, alk phos 60, total bilirubin 16, albumin 42, ferritin 409, vitamin B12 313, TSH 1.90.
Genetic testing for hemochromotosis was all normal.
A/P: This 44 year old gentleman presents with a mild hyperferritinemia. I suspect this is related to alcohol. Certainly there are other causes of iron overload which could account for an elevated ferritin level aside from the two abnormalities which are screened on our routine genetic testing for hemochromotosis. That said, his relatively low iron saturation argues against true iron overload, and as mentioned, I suspected the high ferritin is secondary to alcohol. For now I am not planning any further investigations except to repeat his ferritin in 3 months. He will remain abstinent from alcohol between then and now, and follow up with me a week after those blood test results are available to review and we will go from there. He was happy with these recommendations and I will certainly keep you abreast.
Thanks again for allowing me to participate in the care of your patient.
Sincerely,
Dr. John W. Doe
JWD/pmts
This facsimile and the documents attached contain confidential information intended for a specific individual and purpose. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance of this information is strictly prohibited. If you received this communication in error, please notify us immediately by telephone and return the original to us by fax or regular mail.
Endocrinology and Metabolism
Dr. John Smith, M.D., FRCP(C)
Endocrinology and Metabolism
123 Main Street Tele: 123-456-7890
Anywhere, Ontario Fax: 098-765-4321
A1A 1A1
March 1, 2023
Dr. Random Name
Fax: 555-555-5555
cc: Dr. Another Name, Fax: 252-252-2525, PMH
RE: DOE, Jane DOB: January 1, 1970
Mrs. Doe was reviewed in office today. As you know she had a thyroidectomy in 2014 for bifocal right micropapillary thyroid carcinoma with no adverse features. She did not receive I-131 ablation and remains asymptomatic with no evidence of recurrence. Recent serum thyroglobulin is stable at 0.3 and a recent neck ultrasound show no residual. She has no local compressive symptoms such as dysphagia nor dysphonia nor pain.
Today she weighs 134 pounds. She is clinically euthyroid. The very faint thyroidectomy scar is hardly visible. I cannot palpate any masses in the thyroid bed. Trachea is central. Chest is clear. Heart sounds are unremarkable. There is no tremor. DTR is symmetrical. Abdomen is soft with good bowel sounds.
Currently the patient is quite stable with no evidence of recurrence of her surgically resected bifocal right papillary thyroid carcinoma. I will renew her prescription for Synthroid 100 alternating with 112 mcg for another year with repeat serum thyroglobulin next year. If the thyroglobulin starts to rise, repeat neck ultrasound can then be considered. She can of course return any time if symptomatic.
Yours Truly,
DICTATED BUT NOT READ
John Smith., MD., FRCP(C)
JS/pmts
John W. Doe MD, FRCPC
Gastroenterology, Hepatology and Internal Medicine
Medical Centre
000 Some Street,
Unit 00
Anywhere, ON P9P 9P9
(123)456/7890
Fax (098)765-4321
October 12, 2023
Dr. XXXXX XXXXXX
Fax: 000-000-0000
RE: Last, First
DOB: January 1, 1980
Dear Dr. XXXXXXX,
Thank you for your kind referral. As you know, this is a 44-year-old gentleman referred for hyperferritinemia. He denies any symptoms related to chronic liver disease and there is no history of hepatitis. In general he is in good health and feels well – this was noted on routine blood work. There is no family history of chronic liver disease.
Past Medical History: he has no significant past medical history
Medications: None
Allergies: None
Family History: positive only for coronary artery disease
Social History: no tobacco. He has moderate alcohol use, drinks about a beer a day but sometimes more and he wondered, in retrospect, towards the end of the interview if maybe he drinks more than he readily admits. He is single with no children and works as a technician.
On exam he is awake, alert and oriented
Chest: clear
CV: normal heart sounds, no murmurs noted
Abd: soft, non-tender, no mass palpable, no obvious enlargement of the liver or spleen. No stigmata of chronic liver disease
Ext: grossly normal
Labs: He had a ferritin of 402 on May 30th. In January 2009 his iron saturation was 18 % with an iron level of 10. Hgb 150, MCV 89, platelets 173, glucose 5.1, creatinine 91, ALT 33, alk phos 60, total bilirubin 16, albumin 42, ferritin 409, vitamin B12 313, TSH 1.90.
Genetic testing for hemochromotosis was all normal.
A/P: This 44 year old gentleman presents with a mild hyperferritinemia. I suspect this is related to alcohol. Certainly there are other causes of iron overload which could account for an elevated ferritin level aside from the two abnormalities which are screened on our routine genetic testing for hemochromotosis. That said, his relatively low iron saturation argues against true iron overload, and as mentioned, I suspected the high ferritin is secondary to alcohol. For now I am not planning any further investigations except to repeat his ferritin in 3 months. He will remain abstinent from alcohol between then and now, and follow up with me a week after those blood test results are available to review and we will go from there. He was happy with these recommendations and I will certainly keep you abreast.
Thanks again for allowing me to participate in the care of your patient.
Sincerely,
Dr. John W. Doe
JWD/pmts
This facsimile and the documents attached contain confidential information intended for a specific individual and purpose. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance of this information is strictly prohibited. If you received this communication in error, please notify us immediately by telephone and return the original to us by fax or regular mail.
Endocrinology and Metabolism
Dr. John Smith, M.D., FRCP(C)
Endocrinology and Metabolism
123 Main Street Tele: 123-456-7890
Anywhere, Ontario Fax: 098-765-4321
A1A 1A1
March 1, 2023
Dr. Random Name
Fax: 555-555-5555
cc: Dr. Another Name, Fax: 252-252-2525, PMH
RE: DOE, Jane DOB: January 1, 1970
Mrs. Doe was reviewed in office today. As you know she had a thyroidectomy in 2014 for bifocal right micropapillary thyroid carcinoma with no adverse features. She did not receive I-131 ablation and remains asymptomatic with no evidence of recurrence. Recent serum thyroglobulin is stable at 0.3 and a recent neck ultrasound show no residual. She has no local compressive symptoms such as dysphagia nor dysphonia nor pain.
Today she weighs 134 pounds. She is clinically euthyroid. The very faint thyroidectomy scar is hardly visible. I cannot palpate any masses in the thyroid bed. Trachea is central. Chest is clear. Heart sounds are unremarkable. There is no tremor. DTR is symmetrical. Abdomen is soft with good bowel sounds.
Currently the patient is quite stable with no evidence of recurrence of her surgically resected bifocal right papillary thyroid carcinoma. I will renew her prescription for Synthroid 100 alternating with 112 mcg for another year with repeat serum thyroglobulin next year. If the thyroglobulin starts to rise, repeat neck ultrasound can then be considered. She can of course return any time if symptomatic.
Yours Truly,
DICTATED BUT NOT READ
John Smith., MD., FRCP(C)
JS/pmts
Cardiology Report
John W. doe, MBBS, FRCPC, FACC
Cardiologist
12345 Any Street, Suite 000, Somewhere, ON L0L 0L0
Phone: (123)456-7890 · Fax: (098)765-4321
___________________________________________________________________________________________________
Xxx 31, 2023
Dr. Xxxxx Xxxx
000 Some Street, Unit 111
AnyTown, ON
P1P 1P1
Dear Xxxxx,
Re: Last name, First name
Thank you for asking me to see this 46-year-old man for cardiac assessment.
He tells me around January and March of this year, when he walked in the cold, he felt dyspnea, mild chest tightness, and also flushing in his face. He could only walk for about 200 meters with his dog. These symptoms were quite persistent and happened for about two months. However, after the winter, he has no similar symptoms whenever he exerts himself. He also describes a rather unusual constellation of symptoms at night when he is in bed. This has been going on for about 10 years. He says when he lies down, he feels very uncomfortable and has a sensation that blood is rushing to his chest. He feels like he is about to die and he has to move all his body parts to make himself comfortable. Very often, he is not able to sleep throughout the night. These symptoms occur every night in clusters for a month or so. He is worried that he has some heart problems. He has been well and has no similar symptoms in the last two months. He was in Xxxx last month. He was completely well and had no symptoms in Xxxx. When he came back to Canada, sometimes he has similar exertional dyspnea. He is physically not very active and does not exercise on a regular basis.
He has mild asthma and nasal allergies, fatty liver, and dyslipidemia. He is not a smoker and does not have hypertension, diabetes, pre-existing CAD, CVD, or psychiatric problems.
He takes some bronchodilators, prn Reactine, and prn Nexium. He says he is allergic to Prevacid, Zantac, and Arthrotec.
At the moment, he is unemployed. He lives with his family.
On examination, he looks comfortable, but nervous. BP today was 102/62, heart rate 72 in sinus rhythm. His peripheral pulses were normal. His JVP, carotid arteries, and thyroid were normal. Heart sounds were normal with no murmur and no rub. His chest examination was clear. The rest of his cardiovascular examination was normal.
His ECG today shows sinus rhythm at 64 bpm with no abnormalities and normal QTc interval.
His echocardiogram in the office shows normal left and right ventricular systolic function, LVEF of 69%, no significant valvular abnormalities, and normal RVSP at 29 mmHg.
His stress test at Xxxxxxx in December 2020 was normal. He exercised for 11.5 minutes and had no symptoms and no ECG abnormalities.
Blood work in November 2008 showed normal creatinine, eGFR, FPG, hemoglobin, LDL cholesterol 4.2, lipid ratio 4.0, and total cholesterol 6.2.
Assessment:
This is a 46-year-old man with dyslipidemia and asthma. He presented with a cluster of exertional dyspnea and chest discomfort and facial flushing in the winter. These symptoms have subsided. He also had a bizarre constellation of symptoms at night as described above. His cardiovascular examination, ECG, stress test, and echocardiogram are all within normal limits. I explained the normal test results to him. I do not have an explanation for his unusual nocturnal symptoms. He also had a normal sleep study and no evidence of sleep apnea. However, he is quite convinced that he has some cardiac abnormality.
Because of his persistent concern, I will arrange a CT coronary angiogram to rule out congenital coronary anomalies and other intra-thoracic pathology. He will also get a Holter to rule out arrhythmia, which may explain his unusual nocturnal symptoms. However, I must say that the yield of these tests are quite low. I asked him to call my office after he finishes his tests for the results. I did not put him on any specific medications today. The final possibility for his symptoms is psychosomatism.
Thank you very much for asking me to see him today.
With kind regards,
John W. Doe, MBBS, FRCPC, FACC
(Dictated but not read) pmts
Cardiologist
12345 Any Street, Suite 000, Somewhere, ON L0L 0L0
Phone: (123)456-7890 · Fax: (098)765-4321
___________________________________________________________________________________________________
Xxx 31, 2023
Dr. Xxxxx Xxxx
000 Some Street, Unit 111
AnyTown, ON
P1P 1P1
Dear Xxxxx,
Re: Last name, First name
Thank you for asking me to see this 46-year-old man for cardiac assessment.
He tells me around January and March of this year, when he walked in the cold, he felt dyspnea, mild chest tightness, and also flushing in his face. He could only walk for about 200 meters with his dog. These symptoms were quite persistent and happened for about two months. However, after the winter, he has no similar symptoms whenever he exerts himself. He also describes a rather unusual constellation of symptoms at night when he is in bed. This has been going on for about 10 years. He says when he lies down, he feels very uncomfortable and has a sensation that blood is rushing to his chest. He feels like he is about to die and he has to move all his body parts to make himself comfortable. Very often, he is not able to sleep throughout the night. These symptoms occur every night in clusters for a month or so. He is worried that he has some heart problems. He has been well and has no similar symptoms in the last two months. He was in Xxxx last month. He was completely well and had no symptoms in Xxxx. When he came back to Canada, sometimes he has similar exertional dyspnea. He is physically not very active and does not exercise on a regular basis.
He has mild asthma and nasal allergies, fatty liver, and dyslipidemia. He is not a smoker and does not have hypertension, diabetes, pre-existing CAD, CVD, or psychiatric problems.
He takes some bronchodilators, prn Reactine, and prn Nexium. He says he is allergic to Prevacid, Zantac, and Arthrotec.
At the moment, he is unemployed. He lives with his family.
On examination, he looks comfortable, but nervous. BP today was 102/62, heart rate 72 in sinus rhythm. His peripheral pulses were normal. His JVP, carotid arteries, and thyroid were normal. Heart sounds were normal with no murmur and no rub. His chest examination was clear. The rest of his cardiovascular examination was normal.
His ECG today shows sinus rhythm at 64 bpm with no abnormalities and normal QTc interval.
His echocardiogram in the office shows normal left and right ventricular systolic function, LVEF of 69%, no significant valvular abnormalities, and normal RVSP at 29 mmHg.
His stress test at Xxxxxxx in December 2020 was normal. He exercised for 11.5 minutes and had no symptoms and no ECG abnormalities.
Blood work in November 2008 showed normal creatinine, eGFR, FPG, hemoglobin, LDL cholesterol 4.2, lipid ratio 4.0, and total cholesterol 6.2.
Assessment:
This is a 46-year-old man with dyslipidemia and asthma. He presented with a cluster of exertional dyspnea and chest discomfort and facial flushing in the winter. These symptoms have subsided. He also had a bizarre constellation of symptoms at night as described above. His cardiovascular examination, ECG, stress test, and echocardiogram are all within normal limits. I explained the normal test results to him. I do not have an explanation for his unusual nocturnal symptoms. He also had a normal sleep study and no evidence of sleep apnea. However, he is quite convinced that he has some cardiac abnormality.
Because of his persistent concern, I will arrange a CT coronary angiogram to rule out congenital coronary anomalies and other intra-thoracic pathology. He will also get a Holter to rule out arrhythmia, which may explain his unusual nocturnal symptoms. However, I must say that the yield of these tests are quite low. I asked him to call my office after he finishes his tests for the results. I did not put him on any specific medications today. The final possibility for his symptoms is psychosomatism.
Thank you very much for asking me to see him today.
With kind regards,
John W. Doe, MBBS, FRCPC, FACC
(Dictated but not read) pmts
Radiology Report
EAP PORTABLE CHEST
DATED___
The cardiac silhouette and great vessels appear normal. Minimal infiltrations are noted involving both lower lung fields. Lungs are otherwise clear. There has been a moderate improvement in the lower lung field infiltration when compared with previous study dated ___. Endotracheal and nasogastric tubes are noted in satisfactory position. Central line is noted in place via the right internal jugular vein with the distal aspect located at the right atrium.
DATED___
The cardiac silhouette and great vessels appear normal. Minimal infiltrations are noted involving both lower lung fields. Lungs are otherwise clear. There has been a moderate improvement in the lower lung field infiltration when compared with previous study dated ___. Endotracheal and nasogastric tubes are noted in satisfactory position. Central line is noted in place via the right internal jugular vein with the distal aspect located at the right atrium.
