68, Riverside Clinic
23 August 2019
Re: Mr Craig Hemsworth, aged 52
I am referring Mr Hemsworth, who has been diagnosed with the Tonic-clonic seizure, requires your expert assessment following his discharge today.
On 19 August 2019, Mr Hemsworth was brought to hospital by ambulance followed by a fall at the bus station. After the fall, he became unconscious and ceased breath. Upon assessment, he was conscious, drowsy, bruise on the left arm and the left knee were noticed. After the assessment, the diagnosis was confirmed; therefore, the electro-encephalogram and a computerized tomography scan were performed, which revealed a focal epileptic variants+, as well as a subdural hematoma in the right occipital region was noted. Consequently, he was shifted to ICU, and the neurological review was done by the neurologist and was recommended with injection mannitol 20 mg twice daily, tablet clopilet 75 mg twice daily as well as injection phenytoin 10 mg, injection ceftriaxone 1.5 gram twice per day for five days. Subsequently, he was responded well to the medication and was shifted to the ward for continues monitoring. Today, excellent progress is being identified.
Pertaining to the above-mentioned circumstances, kindly provide the further evaluation and management. The patient has been frightened about the future occurrence of the seizure; thus, proper education about the seizure precausions, avoidance of the heavy activities, driving, and the importance of regular sleep, as well as intake of a healthy diet would be profoundly beneficial.
If you require any additional information, please do not hesitate to contact me at any time.