31th January, 2023
MEDICAL
REPORT
A.C, 38 YEARS,
MALE, WCA/5960/2023
Diagnosis: Mild
Traumatic Brain Injury
Management: Conservative.
The above-named patient presented 3 weeks ago
following a two week history of blunt head trauma. He had been involved in an
altercation at his place of work and was hit on his head. He had post traumatic
headache but no associated seizures or loss of consciousness.
Neurological examination
revealed a conscious, well oriented in time, place and person individual. Motor
and sensory examination was essentially normal. Higher mental function showed
poor judgment and reduced cognition. Brain
Imaging (CT) revealed no brain abnormalities. There was no evidence of
skull fracture.
Following clinical and radiological examination, he was reassured and advised
to continue on non-operative treatment until complete resolution of the
residual brain concussion. Hpwever, he also indicated his interest to seek
second opinion elsewhere.
Kindly accept
assurances of our best regards and kindly revert for clarifications if any.
Yours
Sincerely,
For
Team, Wellington Clinics.