15 May 2011
Re: Ms Maria Joseph, aged 39
I am referring Ms Maria Joseph who requires urgent assessment for suspected intracranial pathology .
On 15 May 2011, Ms Joseph was presented with complaints of frontal headache associated with nausea and blurred vision. Advised her to take rest with analgesics . Yesterday , she was re- presented with complaints of persistent headaches at left frontal associated with vomiting and slight paraesthesia. On examination , her blood pressure was 150/ 90 mm of hg and possibility of severe migraine . Therefore she was treated with pethidine 100 mg and intramuscular injection maxilon , 10mg.
Today during home vist, Ms Joseph verbalized that she fell down at home due to severe left side headache associated with slurred speech and half conscious. In addition, she was injured her right arm and bruise on left leg . On assessment , her pulse is 100, blood pressure is 150/90 , extension power is 4/5 and left leg knee flexion is 4/5.
In view of the above mentioned information, it would be greatly appreciated if you could provide urgent evaluation to improve her health.
Should you have any queries please do not hesitate to contact me.