WRITING TASK

Using the information given in the case notes, write a referral letter
to Dr John Dyer, an ophthalmologist at West Suburban Eye Care
Centre, 396 Remington Boulevard, Suite 340, Romaville requesting
him to look into this case.
In your answer
/
• Expand the relevant case notes into complete sentences
• Do not use note form
• Use letter format

Sample Answer

31101/2017

Dr John Dyer
West Suburban Eye Care Centre
396 Remington Boulevard
Suite 340 Romaville

Re: Mr Tej Singh Randhawa; 41-year-old man

Dear Dr Dyer

I am writing to request an assessment and further management of

Mr Randhawa who is presenting with signs and symptoms consistent
with Horner's syndrome.

Initially, he presented to us on 10/01/2017 c~mplaining of

rhinorrhoea and headaches. At that time, it was suspected that sinus
 Gurleen Khaira 129

pressure was causing the headaches; consequently, he was treated for

infectious sinusitis.

He returned two weeks later with deteriorating symptoms. At

this subsequent visit, he complained of excruciating, right-sided,
throbbing headaches that occurred intermittently and did not subside
despite attempts to rest. Additionally, he reported of concurrent
aching teeth and previously described rhinorrhoea. A diagnosis
of a cluster headache was made, and the patient was prescribed
acetaminophen and non-steroidal anti-inflammatory medications.

On his last visit 2 days ago, he presented along with his wife who
noted that his right eye (ipsilateral to the headaches) seemed
"droopy and sunken" and that his face flushed preceding and during
the headaches. Moreover, the pupil of his right eye constricted in
darkness, and he had decreased sweating on the right side of his face.

Given the above, it would be greatly appreciated if you could assess,

examine, and treat the patient as deemed appropriate.

Should you need further information about the patient, please

contact me with any queries.

Yours sincerely

Head Nurse