1st February, 2023
MEDICAL
REPORT
A.A , 70YEARS, MALE,
WCA/6010/2023
Clinical impression: Vertebrobasilar
Insufficiency from known cervical spondylotic disease to R/O recurrent disc or
adjacent disc disease.
Management: Conservative
management
Background
history
The
above-named patient is a known but controlled hypertensive and presented today
with complain of recent (2months) exacerbation of neck pains radiating to both
shoulders but worse on the left side. No particular aggravating factors but
relieved by rest and neck collar.
He has light sensation of weakness on the left upper
limb. Some impaired competence with gait and balance. He has significant past
history of anterior cervical decompression in December 2019 at NOH (Dala Kano)
due to similar complains & profound weakness on left upper limb.
These symptoms improved tremendously after the
surgery and enjoyed his life until recent.
He has also suffered recurrent attacks of dizziness,
vertigo and in one occasion was reported as hypotension triggering his very
initial symptoms (since 2017). These symptoms have been persistence and bring
concerns.
Neurological
examination: He is conscious, oriented in time,
place and person. Slight gait imbalance.
Full power, tone is intact and reflexes are normal.
MRI
cervical scan pre op shows mild post op lateral discretion at C4. No post op
scans available for review.
Laboratory Results:
FBC:
WBC-4.37, PCV- 38.16
EUCR:
Na- 139.8, K- 3.93, Urea – 21.86, Cl – 104, HCO3 – 21.31, Cr- 0.73, Cal-2.33
FLP:
HDL- 136.2
FBS:
3.59
MRI Cervical Spine shows perfect healing at C3/C4 which was
previously had ACDF cervical lordosis well preserved. Cord architecture well
defined with surrounding subrachnoid space.
CT Angiogram does not suggest any major encroachment on the vertebral artery passage
through the foramen transversarium and posterior fossa circulation is well
outlined. The bony osteophytic processes around the foramen transversanum may
occasionally encroach on the passing vertebral arteries to cause spasms and
compromise the posterior fossa circulation.
Blood test including FLP, FBS, EUCR, FBC were all within acceptable
limit.
Following clinical and radiological examination, the diagnosis above was
made and the management plan outlined.
·
Tab Aspirin
75mg daily.
·
Philadelphia
neck collar.
·
Tab Stugeron
15mg only when needed.
·
Tabs Neurobion
1 daily.
·
Green tea containing senna
·
Physiotherapy
He
was advised to stop driving and will be reviewed again in 3 months (2nd, May 2023)
Please revert,
if need be, for further clarification
Yours
Sincerely,
Dr.
Halima Ibrahim
For
Team Wellington Clinics.