10 August 2021
Dr John Dyer
West Suburban Eye Care Center
396, Remington Boulevard
Suit 340, Romaville
Dear Dr Dyer,
Re: Mr Tej Singh Randhawa; DOB: 09 September 1976
I am writing to refer Mr Tej Singh Randhawa who requires assessment and management. He has suggestive symptoms of Horner’s Syndrome.
Mr Randhawa’s first visit was following an episode of a right-sided headache with significant nasal discharge. On assessment, he was found febrile and diagnosis revealed infectious sinusitis. On subsequent visits, he kept on complaining persistent throbbing right sided headache which was assessed as radiating to the right eye, teeth and the jaw. All examinations pointed to the possibility of a cluster headache and his treatment commenced with acetaminophen and non-steroidal anti-inflammatory drugs.
On a recent visit, Mr Randhawa reported episodic attacks of severe headache associated with rhinorrhea and epiphora. This time, the right upper eyelid was found drooping and the right pupil was found constricting in the dark. However, his vital parameters were in normal limits.
Mr Randhawa underwent thyroid removal surgery for hypothyroidism. Please note, he has the habit of smoking cigarettes and cigars.
It would be appreciated if you could take over Mr Randhawa and provide evaluation and management as deemed appropriate.
If you have any queries regarding Mr Randhawa present condition, please do not hesitate to contact me.