Elizabeth Evans
Dr Fransiska Hutahaean
87 George Town Road NEWNHAM, TAS 7248
16/12/2007
The Registrar
Ophthalmology Department
Sir Charles Gairdner Hospital
NEDLANDS WA 6151
Dear Sir/ Madam,
I am referring Mrs. Elizabeth Evans, 40 years old, who first came to see me on 10/12/2006 with the major complaint of redness and soreness in her left eye. I prescribed Flucloxacillin capsules 250 mg four times daily and Chlorsig ointment applied every 4 to 6 hours.
Four days later she came back with no improvement. On examination I found the swelling in the upper lid was increasing and her lymph glands were also swollen and tender. I prescribed Doxycycline Hydrochloride 100 mg which were taken once a day for seven days.
She came back again today with no improvement at all and she was evasive when asked about medication. I diagnosed her as having a severe eye infection which is not responding to treatment and I am concerned at the possibility of cellulitis. I suspected that she might not be taking her medication correctly.
I am referring her to you for further treatment as she may require hospitalization in order to better monitor medication and intravenous antibiotics.
Yours sincerely
Dr Fransiska Hutahaean
General Practitioner
Probable grade: B
Correction by Kay, the bold ones are the correct ones.
Dr Fransiska Hutahaean
87 George Town Road NEWNHAM, TAS 7248
16-12-2007
The Registrar
Ophthalmology Department
Sir Charles Gaidner Hospital
NEDLANDS, WA 6151
Dear Sir/ Madam,
I am referring Mrs. Elizabeth Evans, 40 years old, who initially presented on 10/12/2007 with the major complaint of redness and soreness in her left eye. It was accompanied by the swelling of her upper lid. I prescribed Flucloxacillin capsules 250 mg to be taken four times daily and Chlorsig ointment to be applied 4 to 6 hourly everyday.
Two days later, she presented again due to a worsening of her condition. The swelling of her upper lid had become severe. On palpation, I found tenderness in her swollen glands. I changed the antibiotics to Doxycyclin Hydrochloride 100 mg to be taken once daily for seven days.
The patient’s condition has not improved with treatment therefore she came to see me again today. She was evasive when she was asked about her medication. I diagnosed that she had a severe eye infection which is not responding to treatment although I suspected that she might not be taking her medication properly. I recommend that she is admitted to hospital to enable her medication regime to be strictly adhered to. She may need intravenous antibiotics because of the possibility of cellulites.
Your assistance in this matter is appreciated.
Yours faithfully,
Dr Fransiska Hutahaean
General Practitioner
Correction by Andrea
http://adrive.com/public/19743c954b76ac0adb79410df0dc420df3fd78fb900eca01c6d4139b0bf8fa9b.html
