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Referral Form for Neurology Consultation

This document is a referral form for a 30-year-old Saudi male patient from the OPD department at Alamal Complex to the neurology department and neurology hospital/PHC. The patient has an 8-year history of poly-substance abuse and recently developed generalized seizures. He is currently being treated with carbamazepine for substance withdrawal seizures but is being referred to rule out organic causes.

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96 views2 pages

Referral Form for Neurology Consultation

This document is a referral form for a 30-year-old Saudi male patient from the OPD department at Alamal Complex to the neurology department and neurology hospital/PHC. The patient has an 8-year history of poly-substance abuse and recently developed generalized seizures. He is currently being treated with carbamazepine for substance withdrawal seizures but is being referred to rule out organic causes.

Uploaded by

raad_alghamdi_1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd

Health Care No 152150 ‫الرقم الصحي‬

Name ‫عبد الرحمن عناد العنزي‬ ‫االسم‬


Age 30 ‫العمر‬ Sex MALE ‫الجنس‬
Nationality SAUDI ‫الجنسية‬
Hospital : ERADAH COMPLEX - Riyadh ‫االستشاري‬
Consultant In-charge ‫فيصل البيشي‬.‫د‬ ‫المسئول‬
.Dept ADDICTION ‫القسم‬ Unit OPD ‫الوحدة‬

REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬


TO DR NEUROLOGY DEPT NEUROLOGY
DESIGNATION HOSPITAL / PHC
FROM DR BISHER FUAD DEPT OPD
DESIGNATION ALAMAL COMPLEX HOSPITAL / PHC ALAMAL COMPLEX
CLINICAL HISTORY :
8 YEARS HISTORY OF POLY SUBSTANCE USE,HASH+ALPRAZOLAM+PREGABALINE, RECENTLY HE DEVELOPED GENERALIZED
SEIZURES.

PHYSICAL EXAMINATION :
WITHIN NORMAL LIMITS

INVESTIGATIONS :
NO ABNORMALITIES DETECTED

PROBLEMS / DIAGNOSIS :
SUBSTANCE WITHDRAWAL SEIZURES

TREATMENT/ PROCEDURES DONE SO FOR :


CARBAMAZEPINE 200 MG BID

PATIENT'S CONDITION : STABLE


REASON FOR REFERRAL : TO RULE OUT ORGANIC CAUSES
TRANSPORTATION :
ESCORT
DOCUMENTS SENT :
Dr.s Name BISHER FUAD
Date : 28/6/1440
Mobile # 0532596272

Print time :<CURRENT_DATE> <CURRENT_TIME> By User ID :<USER_CREATED> DOCUMENT_ID # <DOCUMENT_ID>


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