23 August 2019
Dr Ceawlin Jones
68 Riverside Clinic
Dear Dr Jones,
Re : Craig Hemsworth, aged 52
I am referring Mr Hemsworth who is diagnosed with tonic clonic seizure and requires follow up care following his discharge today.
On 19 August 2019 , Mr Hemsworth was brought to the hospital by an ambulance with symptoms of seizures . On assessment, he was conscious , drowsy, bleeding from tongue, bruise in left arm and left knee . He has relevant past medical history of head injury from a car accident two months ago. However he did not seek for any treatment . He has had hypertension for the past five years and on Amlodipine, 5mg daily.
During hospitalization, he underwent few investigations including EEG and CT scan which reveals focal epileptic variants and subdural hematoma at right occipital region respectively . Therefore, he was commenced on inj. Mannitol 20 mg , inj . Phenytoin 10 mg twice daily . In addition , he was treated with intravenous antibiotics. He was reviewed by opthalmologist and advised to provide rest for eyes.
In view of the above mentioned information, Mr Hemsworth and his wife was educated about monitoring of seizure. Kindly provide ongoing management for him. Of note , explain about safety alert band, sleep, activities and diet.
Should you have any queries please do not hesitate to contact me.