No.

Tel : 085-420033
Hospital Miri
No. Fax : 085-416514
JalanCahaya,
Email : hospitalmiri@moh.gov.my
98000 Miri, Sarawak Web : http://hmiri.moh.gov.my

Date: 7th June 2023

Rehab Physician
Hospital Umum Sarawak.

Dear Doctor,

RE: FOR CONTINUATION OF CARE

Name : WONG MA FOOK @ WONG MA FOK
NRIC : 451110-13-5401
TEL : 012-8997697/012-8923977

The above-named is a 77 years old, Chinese, gentleman with underlying of Diabtes Mellitus,
Hypertension, Dyslipidemia, Stroke in 2016y with no neurological deficit was admitted to Hospital
Miri from 2.6.2023 until 8.6.2023 for Acute Right Posterior Cerebellar Stroke. He was presented
with dizziness for 1 day, occur at 4 am on 2.6.2023, sudden onset with slurring of speech. Upon
arrival at ETD MGH, GCS E4V1M1 with BP is 1175/105 and HR:85, done CT Brain dated 2.6.2023
showed multifocal chronic infarct with background of cerebral atrophy and small vessel disease.On
3.6.2023, patient complain of right sided headache and procced with repeated CT Brain on the
same (3.6.2023) shower acute right cerebellar posterior infarct. Pre-morbidly, patient’s pADL semi-
dependent and using walking frame for the past 5 years and based on her daughter in-law, for the
last 2-3 years, patient always forgetful.

2. During the review in Hospital Miri general ward on 7.6.2023, his cognition is intact,
GCSE4V4M6, he was oriented to time/place/person and able to obey 3 steps commands. He
tolerating NG tube feeding in view of gag reflex absent during admission. Physically his motor
power of all extremities are 5/5. Sensory intact. Done past-pointing finger: left is worse than right
side and done dysdodikenesia: left more worse than right side. We unable to do heel-shin test in
view of patient complain pain on heel-shin test. Functionally he needs maximal dependency with
assistant in all aspect, need 1 man help in sitting-up position. Modified Barthel Index scored 0/100.

3. He is married man with 5 children who live in Kuching, patient lived in a double story house
with seating toilet. Equipment, patient already has walking frame and standard wheelchair.

4. We are referring to your team for continuation of care at your hospital.

Yours Sincerely,

Dr Mohd Shahir
Medical Officer

Department of Rehabilitation Medicine

Hospital Miri