Hospital Medical Report
This form is to be completed by the patient’s hospital doctor
Private and Confidential
Patient’s Name: Tomas Panlilio
Date of Birth: May 18, 1985
Ward: C
Hospital: Philippine General Medical Center
Consultant: Dr. Mina Gemora
Please send a discharge summary including the following information:
When were they admitted to your hospital?
Patient was admitted April 12, 2018
Reason for admission and medical diagnosis
Patient was brought into the emergency room following a collapse, completely unconscious. Patient was admitted following an examination and was not able to be diagnosed immediately. CAT scans were requested and lesions were found in the patient’s brain.
Past Medical History (If known)
No pertinent medical history is known of the patient.
Progress on ward
Patient remains unconscious and in a coma. Patient’s condition has been worsening and it seizures have been observed, mostly during the evening.
Current Clinical Condition
Patient is currently stable, but as of yet, unconscious.
Prognosis and prospects for rehabilitation
Regular checks have been done on the patient, and it seems that the lesions have been growing at a concerning rate. The lesions were thought to be caused by multiple sclerosis, but tests of the patient’s cerebrospinal fluid were negative for the proteins associated with MS. The patient’s condition is deteriorating rapidly with the chances of rehabilitation very slim. Brain damage is severe, even if the patient regains consciousness he may be permanently disabled.
Relevant Laboratory results, x-rays etc.
Attached are the results of relevant bloodwork, CAT scans, etc.
Current Medication
Patient is currently on Levetiracetam for the seizures. As I am still unsure about the diagnosis no other medications have been prescribed as of yet.
Arrangements to follow up
Neurologist Dr. Mina Gemora has been consulting on the patient’s condition. It was recommended to follow up with a visit from Dr. Gaspe Ala, the resident neurosurgeon to help diagnose the patient.
Doctor’s Signature
Dr. Diosdado Engañador
Date
July 12, 2018
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Written by Karl Gaverza
Copyright © Karl Gaverza
Inspired by the Aswang na Gala (Wandering Aswang) legends
Aswang na Gala Illustration by Ped Panlilio
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