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Template of Referral Letter (Sample 1) : History

1) This is a referral letter from a house officer to a neurologist regarding a 45-year-old man who presented with his first unprovoked seizure. 2) The patient has a history of hypertension but all investigations including blood tests, MRI, and EEG were normal. 3) The house officer is referring the patient to the neurologist for expert opinion on further management as the patient has not been started on any anti-seizure medication yet.

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263 views

Template of Referral Letter (Sample 1) : History

1) This is a referral letter from a house officer to a neurologist regarding a 45-year-old man who presented with his first unprovoked seizure. 2) The patient has a history of hypertension but all investigations including blood tests, MRI, and EEG were normal. 3) The house officer is referring the patient to the neurologist for expert opinion on further management as the patient has not been started on any anti-seizure medication yet.

Uploaded by

WY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Template of referral letter (sample 1)

................................Department,
Penang Hospital, Residency Road,
10990 Penang.
___________________________________________________________________________________________________________
……………………………………………….,
………………………………. Department,
Penang Hospital, Residency Road
10990 Penang Date:
Dear Dr.…….,
Re Mr. ABC Age: 45year old (I/C 65010101222)
I would be grateful if you could kindly see and advice regarding management of this right handed
teacher whom I first saw on 20 Nov 2020.

History
Mr. ABC was admitted on 20 Nov 2020 with a first ever unprovoked generalized tonic clonic
seizure. He has a past history of hypertension for 5 years on perindopril 4mg daily. There is no
family history of significance.

Allergies
No known allergy.

Physical examination
Clinical examination was unremarkable.

Relevant Investigation Results:


Baseline blood investigations, cranial MRI and EEG were normal.

Provisional Diagnosis / Sole problem


Late onset first ever unprovoked generalised seizure.

Management
He has not been started on any medication yet.

His family and he have been told that he has had a fit for which no cause has yet been found, and
that he is being referred to a neurologist for expert opinion on further management.

Thank you for reviewing Mr. ABC.


Sincerely,
(DR…………...)
House Officer
H/P: 016-8973316

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