Hello doctor,
I am writing to you regarding a 54-year-old male who had a head injury on the 11th of this month. The computed tomography (CT) scan is dated the 30th of this month. 'A small ill-defined hypodensity in the right posterior frontal white matter extending from the subcortical to the deep periventricular region of a non-specific etiology, probably chronic ischemia. No depressed skull bone fracture or subdural/extradural hematoma'. Presently, the patient is speaking, understanding, eating, talking normally, identifying his family members, etc., but he does not remember what happened to him. There is some memory loss. So, what would be the best treatment? Medicine daily dose details are as follows: Tablet Valprol 500 mg twice a day for one month, tablet Neurobion fort one tablet twice a day for 15 days, and tablet Pantocid 40 mg once a day for one month.
Hello,
Welcome to icliniq.com. I reviewed carefully your uploaded tests (attachment removed to protect patient identity), and would explain that he has had a brain contusion due to the trauma, complicated with small hemorrhage in this area. I agree with his current therapy. I would like to know if he has have had any seizures. The Valproic acid that he is taking is used to control seizures, usually. Take some rest and avoid any repeated head trauma. I would recommend follow up with a brain (computed tomography) CT scan or MRI (magnetic resonance imaging) after three months. Meanwhile,monitoring his blood pressure values and continuing his current therapy. There is no specific therapy in such a case. Besides, he has no symptoms. Doctors usually treat the patient's symptoms and not the MRI findings. These findings will improve spontaneously after some time.
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