Referral letter

Year 3 BDS – II posting

A 57-year-old male patient from Melaka reported with a
complaint of non-healing ulcer on his right buccal
mucosa. He is a chronic smoker. His biopsy report is
suggestive of poorly differentiated squamous cell
carcinoma. Refer this patient to an appropriate
treatment center.

Case 1 - Demo
 Answer
From,
Dr. XYZ, Klinik Pergigian, FOD, MMMC, Melaka
To,
Oncologist/ surgeon
Oral Cancer centre, UM, KL
Sir/ Madam,
Hereby I am referring a 57-year-old male patient who visited my clinic with a
complaint of non-healing ulcer on his right buccal mucosa. As the ulcer was long
standing and local factors were ruled out, an incisional biopsy was performed and the
specimen was submitted for histopathological diagnosis. He was diagnosed with
poorly differentiated squamous cell carcinoma of right buccal mucosa. Please find the
attached histopathology report and slides (H & E stain) for your reference. Kindly
evaluate the patient and do the needful treatment.
Thanking you,
Yours sincerely,
Dr. XYZ,
Date:
Case 18
Exercise number 1
A 57-year-old female patient came to the dental clinic for extraction of
teeth which were grossly decayed or broken. She is hypertensive and
diabetic. Her BP is 180/96 mm of Hg on right arm at sitting position and
random blood sugar is 9 mmol/dl. The dentist decided to get clearance
from her physician before extracting her teeth.

Write a referral letter to this patient.

Exercise number 2
A 52-year-old gentleman came for implants and gave history of bypass
surgery few months back. He is currently under warfarin tablets and his
INR is 2.6. His BP is 140/90 mm of Hg on his right arm in sitting
position.

Write an appropriate referral letter to this patient.

Exercise number 3
The OPG of a 33-year-old man showed complete radiopacity of right
maxillary sinus. He complained of pain in that region for the past 3
months. He had come to the dental clinic for pain in the right maxillary
teeth and referred pain due to maxillary sinusitis was suspected.

Write an appropriate referral letter to this patient.

Exercise number 4
A 45-old-lady was referred to dental clinic by an ophthalmologist to
check for any foci of infection. After examination, the dentist found no
infected teeth and ruled out any foci of infection.

Refer back the patient to her ophthalmologist with an appropriate

referral letter.