FSP Arztbrief 05: Fahrradunfall

Sample Doctor’s Letter (Case 05: Bicycle Accident – Laura Becker, 31 years) – a complete example of an FSP-style medical letter after trauma. It demonstrates the full structure from salutation and introduction through acute history (dooring accident, head impact without helmet, brief loss of consciousness, post-traumatic amnesia, initial confusion), current symptoms (headache, neck pain, dizziness; no vomiting), vegetative history and stability, past medical history/medication/allergies (penicillin allergy; tetanus up to date), plus social and family history.

The summary and assessment include suspected concussion (mild traumatic brain injury) and suspected cervical sprain without focal neurological deficits. Recommended next steps include 24‑hour inpatient neurological monitoring, CT head if clinical deterioration/persistent severe headache, analgesia as needed, and physical/cognitive rest, ending with a professional closing.