6th February, 2023
MEDICAL
REPORT
I. Z, 28YEARS, MALE,
HOSP
NO: WCA/1570/2016
Diagnosis-
Post VP shunt revision
Management Plan-
Shunt series and counseling.
One
month post shunt revision walked in by himself and complains of discomfort,
pain and stiffness on right side of neck. Recall that he had a shunt revision (December
2022) on account of disconnection of proximal from distal end of VP shunt near
the root of the neck with resultant formation of pseudo – meningocele. He has recalled that 6yrs earlier he suffered
visual failure which was attributed to optic neuritis / IIH and required initial lumbar drain insertion and
subsequently converted to shunt. He improved symptomatically with his vision
and general wellbeing until recent December 2022.
Wound
is healed both cervical and abdominal scar.
Management Plan:
·
To do shunt series.
·
X-ray of neck, head, and chest abdomen.
·
CT scan Brain.
·
Review with investigation result.
CT with Shunt Series – shows
well positioned ventricular catheter and shunt traversing head, neck, chest,
and well positioned in the abdominal cavity.
Plan:
·
Reassure patient that everything is fine
·
To see in 12months time ( 06/02/2024).
Please revert,
if need be, for further clarification
Yours
Sincerely,
Dr.
Halima Ibrahim
Team
for wellington clinics.