Jason Gurning
Dr Fransiska Hutahaean
87 George Town Road
NEWNHAM, TAS 7248
24 September 2007
Dr B Aritonang
Accident & Emergency Department
Launceston General Hospital
Launceston TAS 7250
Dear Dr Aritonang,
Re : Jason Gurning
DOB : 24 April 2007
This five-month-old baby came to me yesterday with the major complaint of being unwell with a cold. The investigation showed nothing abnormal except mildly hyperemic tympanic membranes.
I kept him in my surgery for a while for monitoring. Finally, I sent him home after he was fed a little by breast milk and looked better. My diagnosis at that time was unspecified viral infection.
He came back this morning with restlessness through the night and he looked a little irritable. He refused to feed through the night.
On examination today I found a rise in temperature from 37,1°C yesterday to 37,3°C today. There was no photophobia or stiffness in the neck.
I am referring him to your department because for an immediate lumbar puncture. I would appreciate your assessment and management.
Yours sincerely,
Dr Fransiska Hutahaean
Probable grade: B
Correction by Kay.
http://adrive.com/public/51840de2ac91a7edd10dda5628a7097984beba4d829c6e23571ed18f4529b216.html
