23rd January 2023.
TO WHOM IT MAY CONCERN
MEDICAL
REPORT
K. O, 36 YEARS, MALE
WCA/5932/2022
Diagnosis: Multiple
Skull lesion - multiple myeloma, metastaic lesion primary
Operation
Performed- Stealth Guided Biopsy of Right Parietal Convexity Mass Lesions
Date
of operation- 23rd Jan 2023
Back
ground Presenting Information:
The above-named patient presented to this facility with
a one month history of headache and blurry vision for nine days. Headache is
generalized ,gradual in onset progressively worsening and ,feels like a burning
sensation on his head. It,radiates down to his neck suboccipital regions as
well as down the spinal axis and the limbs in a very unspecific pattern.There
is no known relieving or aggravating factors .No vomiting,no nausea,no LOC, no
seizure.
Neurology
examination findings -His pupils were 3mm bilaterally,
non reactive bilaterally with no perception to light bilaterally. GCS-15/15
E-4, M-6, V-5
He was initially reveieded by a neurologist in view
of the non specific axial and appendiculatr pains with a suspicion of
Spondylotic diseases of the spine but nothing significant was found but on
account of the blurring of vision, he was referred to the ophthalmologist who
intern recommended brain scan. This showed multiple osteolytic mass lesions
with the following differential diagnosis- multiple myeloma, metastatic
deposits etc
A STEALTH GUIDED BIOPSY targeting one of the right parietal
convexity lesions was recommended. He was counseled and planned for
the procedure accordingly
Pre-
op Management
·
FBC – WBC- 5.47, PCV- 44.51%, PLT- 279.
·
E/U/Cr – Na-144.1, K- 3.66, Ur- 11.86,
Cr- 0.57.
·
Clotting Profile – APPT- 32.9, PT-12.6, and
INR-0.9.
·
Serology – Non reactive for HIV1&2,
VDRL, HCV and HbsAg.
·
Brain MRI- Multiple skull lesions
·
ECG – Normal findings.
·
Group and cross match one pint of blood.
·
DVT Prophylaxis – TED stockings applied.
·
Informed consent taken.
Imaging
·
Pre-operative contrasted MRI brain
revealed Multiple skull lesion on his skull. Largest at the occipital measuring
4x 3cm
· Contrast enhanced stealth CT brain was done to facilitate Neuronavigation procedure
·
·
Operative
Findings
·
3 x 3cm fleshy yellowish white fleshy
mass.
·
Markedly thinned out skull bone surrounding
the tumour.
·
No overlying skull bone on the tumour
Operative
Procedure-
·
Under GA + ETT
·
Patient was placed supine position and
Mayfield pin.
·
Sterile cleaning & drapping
·
Cold registration of patients fudisial with
the stealth machine and stealth guided localization of surgical site
·
5cm linear incision made centered on the
tumour, Hemostasis secured
·
Via meticulous dissection, the tumour was
dissected around and a plane developed
between it and the dura , then excised in bloc
·
Above findings noted.
·
Tumour bed haemostasis secured.
·
Wound drain was placed.
·
Wound closed in layers with vicryl 2/0
and staples
·
Immediate Post op satisfactory
Post
op Managements.
·
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 Tramadol 50mg 12hrly x24hrs
·
Commence oral sips when fully awake
·
IV Dexamethasone 4mg 8hrly x 24hrs,then
·
Tabs Dxamethasone 2mg tds
·
Tabs Rabreprazole 20mg dly.
·
Counsel patient on surgical findings and
other treatment plan.
·
Send specimen for histology.
His post op recovery
from anesthesia is uneventful and his post op medications will be administered
as prescribed. Thereafter he will be discharged home. Histology report is
expected within the next two weeks after which a definitive treatment will be advised
based on the outcome of the histology report.
Please consider this a
preliminary report and contact us again for any further clarifications.
Dr
Halima Ibrahim MD
For Team Wellington Clinics Abuja