Dear Dr.

J Howe
Neurosurgeon
Spirit Hospital
Wooloongabba

12 September 2017

Dear Dr. Howe,

Re: Mr. Arthur Benson, DOB: 15/04/92

I am writing to refer Mr. Benson, a 25-year-old computer programmer and a father of 6-month-old
twins, who is presenting with signs and symptoms of subdural hematoma.

Mr. Benson was hospitalized due to a car accident during the past three months and discharged after 24
hours with no complications. He has been taking a steroid inhaler for childhood asthma. Please note
that he is allergic to penicillin.

On 25/08/17, Mr. Benson presented a two-month history of headache associated with a mild sensation
of pins and needles. On examination, there was mild weakness in the left hand along with lumbar
lordosis. Additionally, his BMI was 32 for which I advised him to reduce his weight and increase exercise.
Therefore, he was advised to take a rest for 2 weeks and prescribed Panadol 2 tab.

On today’s visit, Mr. Benson’s symptoms have worsened with severe headaches and blurred vision for 3
days with a mild response to Panadeine Forte. On examination, there was a loss of sensation in the
medial aspects of the left hand and wrists. Additionally, his blood pressure was 160/70 with odematous
optic disk on fundi examination.

In view of the above, I believe that Mr. Benson needs to be referred to a neurosurgeon for further
assessment and management including an MRI scan.

Please contact me for any further queries.

Yours sincerely,

Dr. Kay