Dr John Dyer
West suburban Eye Care centre
396 Remington Boulevard
31 January, 2017
Dear Dr Dyer,
Re: Mr Tej Singh Randhawa, aged 41
I am referring Mr Tej Singh Randhawa, whose signs and symptoms are suggestive possibility of Horner's syndrome. He requires urgent assessment and management at your esteemed facilities.
On 10 January, Mr Randhawa presented our clinic with complaints of right side headache accompanied with nasal discharge. His vital signs shows fever and he was started with Augmentin for his infected sinusitis. On 24 January, He had severe headache which was throbbing, radiating to right eye, teeth and jaw that last about 15 minutes to more than 2 hours. Pain was intermittent and rated 10 out of 10. Neck tenderness on the right side is reported. He was commenced with acetaminophen and non steroid anti-inflammatory medication.
Two days ago, Mr Randhawa accompanied with his wife. He had previous complaints of severe headache associated with rhinorrhea and epiphora. On physical examination, it reveals dropping of upper eyelid, constriction of Pupil in his right eye and facial flushing is noted before and during headache.
Mr Randhawa lives with his wife and daughter in his own house. He had a history of hypothyroidism. He was admitted to the hospital in 2010 for appendicitis.
In view of the above circumstances, your expert guidance would be beneficial to improve Mr Randhawa's condition.
Please do not hesitate to contact me for further query.