Dr J Howe
12 september 2017
Dear Dr Howe
Re: Arthur Benson , aged 25
I am retering mr benson , whose signs and symptoms are suggestive of sub dural neamatoma, your further evaluation and appropriate management will be appreciated.
Regarding his medical history , mr benson had a car accident three months previously . however his post twenty four hours hospital observation and CT scan report were un remarkable . He has asthama, for which he taken steroid inholer . please note , he is allergic to penicillin .
Initially on 25/08, mr benson pesented with mild headache 2nd left hand number, no history of nausea or vomiting . on examination a BMI(b2)lumbar lavdisis and mild left hand weaknen were noted .subsequently , pandol two tablets every six hours was prescribed additionally apprised regarding weight reduction, maximized physical activities and sick leave for two week were provided. two week later his condition was improved in addition to 3 kgs weight reduction and increased exercise were reported . therefore , return back to work and contact if he devolop any symptoms recommendations were given .
on today's vinit, mr renson was suffering from severe headache for three days , dizzinen , anorexia and blured of resion . physical examination revealed on increased BP 160/70, oedmatous optic disc, reduced vesion field . In addition to absent wrint reflexes and diminished power and sensation were noted at the medical aspects of the left hand.
Based on the above clinical features, I believe further investigation , included MRI scan , would be extremly beneficial .
In case you require any additional information , please do not hesitate to contact me.