26th January 2023.
TO WHOM IT MAY CONCERN
A. B, 46 YEARS, MALE,
Diagnosis: LEFT CHRONIC SUBDURAL HEMATOMA
Operation Performed- LEFT FRONTAL AND PARIETAL BURRHOLE CRANIOTOMY FOR EVACUATION OF CHRONIC SUBDURAL HEMATOMA.
Date of operation- 30th JAN 2023
Surgeon: Dr Charles Ugwuanyi.
Back ground Presenting Information:
The above named patient presented on account of referral from a peripheral center with symptoms of recurrent headache of 2 weeks duration and vomiting of 3 days duration.
He was in his usual state of health until about 2 weeks ago when he started having headaches. Initially left sided but later became generalized, increasing in intensity in the last 4 days with a VAS score of 9/10. There is associated vomiting non projectile, about 3 episodes, non bloody, containing recently digested meals. No history of blurry of vision, seizures, no weakness of any side of the body, no loss of consciousness, no history of facial deviation. There is no history dizziness, neck pain, no neck stiffness, and photophobia. He is a known hypertensive on amlodipine and telmisartan.
Neurology examination findings -His pupils are 3mm bilaterally reactive to light. GCS-15/15 E-4, M-6, V-5, Normal tone, power and reflexes in all limbs.
Based on the above findings, the above diagnosis was made and disscussed with patient. Consent was gotten.
Pre- op Management
· FBC – WBC-6.5, PCV- 43%, PLT- 214.
· E/U/Cr – Na-139, K- 4.19, Ur- 33, Cr- 0.98.
· Clotting Profile – APPT- 24, PT-11.7, and INR-0.9.
· Serology – Non reactive for HIV1&2, VDRL, HCV and HbsAg.
· Brain CT- showed left chronic subdural hematoma
· ECG – Normal findings.
· DVT Prophylaxis – TED stockings applied.
· Informed consent taken.
· Pre-operative CT brain showed left chronic subdural hematoma with a midline shift
· Thickened discolored Dura
· Dark/chocolaty chronic subdural bloody collection under considerable pressure pushin brain to contra lateral side
· Underlying pia/arachnoid found to be pulsating
· Under GA + LMA
· Sterile cleaning & draping
· Placed supine position with head to contra lateral side exposing fronto-patietal region
· Frontal and parietal borehole made
· Above findings noted.
· Dura excised to release CSDH under pressure
· Adequate irrigation
· Wound drain was placed.
· Wound closed in layers with vicryl 2/0 and staples
· Immediate Post op satisfactory
Post op Management.
· Transfer to ICU for recovery after extubation.
· IV Fluid 0.9% N/S 1L 8hrly for 24hrs
· IV Rocephine 1g 12hrly
· IV PCM 600mg 8hrly x 24hrs
· IV Phenytoin 1G in 250mls of N/S stat and then 300mg nocte for 2 days
· Commence oral sips when fully awake
Immediate post operative period was uneventful. Drain was taken out 48hrs post op and opening sutured airtight.
He completed his 48hrs dose of IV antibiotics and was commeneced on tabs zinnat 500mg twive daily for 5 days.
Brain CT done 48 hrs post opp showed resolved chronic subdural hematoma with mild pneumoceplaus. See image below.
He developed subgaleal hematoma 3days post opp and was commenced on Tab Furosemide 20mg dly, Tab Chymoral I bd.
Discharge Instructions and Medications:
· He will continue tab Zinnat 500mg bd x 1/52
· Tab Vit C 1G dly x 2/52,
· Tab PCM 1g tds x 5/7
· Tab Dexamethasone 2mg bd x 2/7, then 2mg dly x 1/52, then 2mg alternate days for 1/52
· Tab Chymoral I bd x 5/7
· Tab Furosemide 20mg dly x 5/7
· Alternate day wound dressing
He would be reviewed again in 4 weeks,
Please revert, if need be, for further clarification
Dr Halima Ibrahim MD
For Team Wellington Clinics Abuja