TASK 33 Patient History:

Constance Maxwell is a patient in your General Practice. DOB 8.8.34 Married, 3 adult children

21.2.06 Subjective:    Complains of inflamed, sticky and weeping eyes. Thyroidism diagnosed Feb.03

High blood pressure June 05,Hip replacement July 05

Medications thyroxine 1mg daily, Atacand 4mg daily, Fosamax 10mg daily No known allergies

Objective: BP 135 /75 P 74

Both eyes red, watery discharge right eye worse than left

Assessment: Bilateral conjunctivitis likely viral Chlorsig Drops 4hrly

3.3.06 Subjective:                  No improvement to eyes, blurred vision

Objective: Odema eye lids ++Marked conjunctival congestion

Plan: Chloramphenicol 0.5% sterile 1 drop 3 times daily Bion Tears 1 drop each eye 4 hrly. Review 2 weeks

5.6.06 Subjective: Accompanied by husband. Very distressed. Has lost most sight in both eyes can make out light or dark shapes but unable to read or watch TV.

Objective: Marked oedema upper and lower lids. White sticky discharge Unable to read eye chart

Plan: Refer immediately Emergency Dept. Royal Melbourne Eye hospital. Husband will drive to hospital

WRITING TASK Using the information in the case notes, write a letter of referral to the Registrar, Emergency Department, Royal Melbourne Eye Hospital, Alexandra Tce, Fitzroy, Melbourne 3051