TASK 45 Mr.Tej Singh is a 41-year-old man who has been a patient at a clinic, you are working in as a head purse,                                              

Today’s date  : 31/01/2017   Name  : Mr. Tej Singh Randhawa

DOB    : 09/09/1976              

Address          : 28, Raymond Street, Romaville

Medical history         : Hypothyroidism thyroid replacement

No history of trauma or weight loss Hospitalized (2010) due to appendicitis No POHx (No previous ocular history) No allergies Immunizations are current Smoker (Cigarettes & Cigars) Teetotaler

Social history             Works.as a systems Analyst

Arrived in Australia from India with wife in 2012 as a permanent resident Lives In own home

Married – Wife Mona Randhawa aged 37 1 daughter

10/01/2017      Subjective: Headache, right-sided, no cough, no dizziness, denied vomiting and nausea.

HA accompanied with significant nasal discharge.

Objective: P 96, BP 130/70, T 101.0 f, neuro exam normal, neck supple.

General Assessment: Alert, Well-nourished, well-developed man, infectious sinusitis.

Plan: Given Augmentin (Amoxicillin/clavulanic acid)

24/01/2017 Subjective: Complaints of severe headaches (HA), right-sided, throbbing, radiating to light eye, teeth, and jaw lasting 15 mins to < 2 hrs, persistent HA intermittent episodes, pt described pain as “like someone has put red hot poker in my head.” Pain so severe (10/10) that pt. unable to stand still, sit down or go to bed, no effect when light/noise avoided rhinorrhoea, no nausea, no vomiting.

Objective: P 105, BP 150/90, physical & Neuro exam normal, neck tender right side.

Assessment: Cluster Headache.                          

Plan: Given acetaminophen and non-steroidal anti-inflammatory.

29/01/2017                 

Subjective: Pt accompanied by wife, Mona

Previous complaints of severe headaches- occurring in episodic attacks associated with rhinorrhoea and epiphora.

Right eye “Droopy and sometimes as “sunken” eyelid, first noted by Mona 1 day ago, facial flushing before and during HA.

Objective: Right eye upper eyelid drooping, constriction of pupil right eye in dark lighting, decreased sweating on right side o face. P 95 BP 130/85                                  

Assessment: possibility of Horner’s syndrome.

Referral plan: referral to ophthalmologist for further evaluation and management

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.

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