Updated: Jul 29, 2021
Dr. Robert Edwards Neurologist
Ruch ford Hospital
765 Long Gulf Read Littletown
24 February 2018
Dear Dr. Edwards,
Re: Ms Sarah Day, aged 20
Thank you for accepting Me day, whose clinical features are consistant with the complication of Whiplash Injury, for further evaluation and appariate treatment.
Initially, on 6 December, Mr Day attented with her mother with the complaints of unilateral steady occipito- temporal headache radiated to the vertex. The condation was associated with dizzines, anorexia and Vesion impairment that relieved by lying down. Notriggers facter have mentioned and not precipstand by the stress of menstural cycle. The headache was described an rapidonset with cure, high intensity lasted severed hous. Neurological examination was unremarkable. Subsequently, adequate sleep was encourged. régular healthy meals was advised, information regarding dark and ice was delivered and metoclopramide 10mg along with regarding a pararetmol 1g every four hows were prescribed.
On the subsequens visits, Ms Days exchibited repeatedly attacks, worsening of her previour symptoms, rousiting and neck pain. Additionaly, Socail with drawal, fearfulness from the outdoor activities were required, respence to the previous medication waspoor. Accordingly, eletriptan 40 mg, endly for the attack and ibupaten 40mg six hourly commenced. However, side effect to eletriptan who reported, No recovery was intermed. Furthermore, Clinical depression cyr plans and signs ware developed. Therefore, amitriptyline 25 mg twice daily. was axdoned.
On today's visit, Ms Day attented alone suffered from numbrig and tingling in the ring and small finger, both hands. History of whisplash injury, due to car accident in 2017 was intermed, for, which no mangement was received and the mother not illuminated.
Based on the above-mentioned medical condation, your further assessment and management would be extremly beneficial.
If you require any additional information, please do not hesitate to contact me.