Optometry

Notes: Today's date is 10 September 2029. You are an optometrist at a local clinic. A patient with diabetic retinopathy needs a referral to an ophthalmologist for further evaluation and treatment.

PATIENT DETAILS:

NAME: Mr. Daniel Turner

DOB: 22 May 1960 (69 y.o.)

Social background: Married, two adult children

Occupation: Retired accountant General health: Type 2 diabetes (well-controlled with medication), hypertension (well-controlled with medication)

Family history: Mother had glaucoma

Patient history:

2010 – Diagnosed with type 2 diabetes, managed with medication

2015 – Hypertension diagnosis, managed with antihypertensive medication

10 September 2029

Presenting problem: Decreased visual acuity and recent onset of floaters in both eyes

Both eyes:

• Gradual decrease in visual acuity over the past year

• Recent onset of floaters

• No eye pain, redness, or discharge

• Known history of well-controlled type 2 diabetes

Visual acuity (VA): Right eye 6/36, Left eye 6/36

Colour vision (D-15): Normal

External examination:

• No obvious abnormalities

• No signs of lid abnormalities, ptosis, or swelling

Slit-lamp examination:

• Mild bilateral cataracts

Fundoscopy:

• Bilateral diabetic retinopathy with macular edema

• No evidence of retinal detachment or other retinal abnormalities

Diagnosis: Diabetic retinopathy with macular edema

Initial treatment: Referral to an ophthalmologist for further evaluation and treatment.

Writing Task:

Using the information given in the case notes, write a referral letter to Dr. Sarah Adams, an ophthalmologist, requesting further evaluation and treatment for Mr. Daniel Turner's diabetic retinopathy with macular edema. Address the letter to Dr. Sarah Adams, Ophthalmologist, VisionCare Clinic, 321 Vision Way, Visionville. In your answer:

• Expand the relevant notes into complete sentences.

• Do not use note form.

• Use letter format.

• The body of the letter should be approximately 180–200 words.