Arthur Benson

Today's Date - 12/09/17

Patient History

• Arthur Benson

• DOB: 15/04/92
• Computer Programmer

• Regularly works 55 - 60 hr a week

• Married with twin boys aged 6 months

• Non-smoker and social drinker

• Father died at 69 due to stroke

• Mother is a diabetic on metformin

P.M.H

• Asthma since childhood - on steroid inhaler

• Allergic to penicillin

25/08/17

Subjective

• c/o headache (2/12), mild sensation of pins and needles, no nausea or vomiting

• Had a car accident 3 months ago. Hospitalised and discharged after 24 hrs with no
complications.

• CT scan normal

Objective

• O/E - overweight , BMI - 32

• Gait - normal, has lumbar lordosis

• Mild weakness in L hand

• Vision - good

Plan

• Review - 2/52
• Panadol 2 tab 4/24 and rest 2/52
 • Advise to reduce weight and increase exercise

06/09/17

Subjective

• Feeling better, no new complaints, no worsening of pins and needles sensation

• Has been walking 30 minutes 3 times a week

• Advised to start work and come back if any concern

Objective

• Weight loss 3kg

12/09/17

Subjective

• c/o worsening headaches for 3 days, dizziness, nausea, blurred vision

• Pain not responded to Panadol but noticed mild response to Panadeine Forte

Objective

• No weight change

• Gait - normal

• Could not read 2 lines of eye chart

• Oedematous optic disk on fundi examination

• BP - 160/70 , PR - 98 bpm

• Mild weakness and loss of sensation in medial aspects of L hand

• Reflexes: Elbow-normal, Wrist- no reflexes

Diagnosis: Subdural haematoma

Writing Task

You are a General Practitioner at a suburban clinic. Arthur Benson and his family are regular

patients. Using the information in the case notes, write a letter of referral to a neurosurgeon

for MRI scan. Address the letter: Dr J Howe, Neurosurgeon, Spirit Hospital, Woolloongabba.