Dr Ceawlin Jones
23 August 2019
Dear Dr Jones
Re: Mr Craig Hemsworth, aged 52
Mr Hemsworth who is recovering from Tonic Clonic seizure, requires continuous care and management. He is being discharged back to your service today.
Upon admission, Mr Hemsworth was accompanied by his wife to emergency department. She reported that he had sudden fainting and unconsciousness, while waiting for the bus. In addition, jerking movements of upper and lower limb were evidenced for two minutes. He stopped breathing for 20 seconds, consequently, he had facial cyanosis, followed by urinary incontinance. Nevertheless, he recovered after two minutes and complained about headache. He was disoriented, drowsy and bleeding from his tongue.
During his time in hospital, investigations were done. Haemoglobin was 11.7 mg, White blood cell count was 11200 cells/mm cube, electroencephalogram revealed focal epileptic variants and Computed Tomar Graffi scan showed subdural haematoma of the right oocipital region. As a result, he was admitted to intensive care unit where neuro consultation was provided. He was managed with IV medications such as mannitol 20mg bd, Phenytoin 10mg bd and cerftriaxone 1.5g bd for five days. He was also given the tablets such as clopilet 75mg bd and amlodipine 5mg OD. The following day his condition was significantly improved and he was discharged to the word. Ophthalmology review was adviced two days later.
Based on the above, Mr Hemsworth needs progressive care and monitoring. Continuing and convulsants medication would be profoundly beneficial.
If you have any queries, please do not hesitate to contact me.