Woods & Water Medical Center

600 N 21st Street

Superior, WI 54880

April 25, 2018

William Abbott, MD
Toledo Medical Center
4523 Monroe Avenue
Toledo, OH 43605-2400

Dear Dr. Abbott

RE Phil Neuman
DOB: 6/30/55

I appreciate the referral of Mr. Neuman, whom I saw in consultation on the 1st of April. The
present diagnosis is idiopathic perennial rhinitis and a presumptive diagnosis of bronchial
asthma. Since December of 1992, he has had multiple courses of antibiotics for bacterial
infection of the paranasal sinuses.

The patient’s occupation since childhood is farming. In March of 1990, he took a job that
exposes him regularly to fossil-fuel combustion products. He has had symptoms of facial
discomfort, postnasal drainage, and nasal obstruction on both sides for 10 years but
progressively worsening over the past 2 years. Within the past year he has developed
symptoms of congestive chest wheeze and breathlessness, which are consistent with, but not
diagnostic of, bronchial asthma.

Physical examination reveals a well-developed and well-nourished normotensive Caucasian

male whose external facial features are normal. He has a superior anterior left nasal septal
deflection, and the nasal mucosa is deep red but not strikingly edematous. The tonsils were
moderate in size. Minimal cobblestoning of the posterior pharynx was noted, and there is the
suggestion of auscultation of the chest for the presence of a low-intensity
inspiratory/expiratory wheeze. The heart was normal.

His medical system review indicates that he had a traumatic splenectomy in 1991 and received
pneumococcal vaccine in 1995. He has been subject to recurrent gingival abscesses and dermal
furunculosis, although he has had none of the former for 4 years and did not have any specific
periodontal procedures done to explain their disappearance. He has not had otitis media,
urinary tract infections, or chronic diarrhea. Nasal congestion and postnasal drainage failed to
improve on Beconase, but did improve on Nasalide Nasal Solution.
Evaluation of pulmonary function revealed a pattern of small airways dysfunction. The degree
of abnormality is not often associated with auscultatory abnormality. However, the patient’s
true
William Abbott, MD
Current Date
Page 2

normals may exceed the predicted, making the current findings more significant. The patient’s
allergy skin tests were completely negative other than prick test responses to tomato and green
pepper.

A dietary history does require looking at tomato, but not green pepper, as a possible
contributory factor for the patient’s symptomatology. However, I have advised a stricter allergy
dietary program, which he will begin after he returns from proposed vacation. If dietary
management fails to produce results, then I feel IgE, QIA, and quantitative IgG4 studies are
indicated. If these are normal, then the patient’s choices are surgery, topical corticosteroids,
topical corticosteroids with use of antibiotic and supplemental oral corticosteroids for a
bacterial flareup, or topical corticosteroids with prophylactic antibiotic on a daily basis.

Please send me a copy of your evaluation in order that I may confirm the patient’s opinion that
you feel maxillary antrostomies, right ethmoidectomy, and nasal septal repair are indicated
because of the presence of significant inflammatory sinus disease.

Sincerely yours,

Ming Wong, MD
Allergy Department

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