TO WHOM IT MAY CONCERN
MEDICAL
REPORT
M.A, 44 YEARS, FEMALE
WCA/5959/2023
Background
Information:
The above-named patient was referred to this facility with
a 3- week history of sudden headache with immediate closure of her right
eyelids. Headache is described as the worst imaginable headache of her life
with associated vomiting. No dizziness, seizures or loss of consciousness. She is a known hypertensive of 28 years who
is non compliant with medication.
On examination, satisfactory general physical
condition, right nerve III palsy (right eye ball deviated out and downwards,
right pupil dilated, eyelid closed. CT Angiography confirmed a Right Posterior
Communicating Artery aneurysm (PCOM)
Above diagnosis was explained to the patient and
referring physician especially the need to proceed with the prescribed
microsurgical clipping of the aneurysm after due consent and in clear
consideration of the benefits and potential complications.
Pre-operative
Planning:
Pre- op Investigations and Management
·
FBC – WBC- 6.1, PCV- 33%, PLT- 184.
·
E/U/Cr – Na-135, K- 3.3, Ur-3.4, Cr- 43.
·
Clotting Profile – APPT- 38.1, PT-12.2, and
INR-0.9.
·
Serology – Non reactive for HIV1&2,
VDRL, HCV and HbsAg.
·
Chest X-ray - Normal x-ray findings
·
Brain MRI
·
CT Brain + Angiogram Review
·
ECG – Normal findings.
·
Group and cross match 3 pints of blood.
·
DVT Prophylaxis – TED stockings applied.
·
Informed consent taken.
Pre-Operative
Imaging
CT Brain
CT Angiogram and MRA
Operative
Intervention-
PCOM aneurysm clipping.
Intra-Operative
Findings
·
Circular aneurysm situated about 1cm
distal to the intradural segment of the right ICA closely related to the PCOM
aneurysm. Anterior choroidal artery as well as terminal division of the
internal cerebral artery (A1 and M1) was dissected and visualized and normal.
·
Some arteriosclerotic plaques located on
the wall of the ICA and neck of circular aneurysm.
Operative
Procedure -
·
Under GA + ETT
·
Routine cleaning and draping
·
Supine position, head located to the left
side and fixed on Mayfield pins.
·
Craniotomy via the right pterional
cutaneous flap.
·
Bone flap removed and drilling of sphenoid
ridge down to the sphenoid process.
·
Durotomy performed in a curvilinear
fashion with dura exposed.
·
Subarachnoid commenced from the lumen
insulla from the region of the anterior sylvian point.
·
Subarachnoid dissection continued
internally.
·
Carotid system identified and opened
distally up to the termination of the ICA.
·
Above findings noted.
·
Dissection around the neck of the aneurysm
performed to create a passage around the neck.
·
PLS NOTE: RUPTURED ANEURYSM AT DOME was
encountered, however with hypotensive anesthesia and gentle packing with
surgicell, a straight 10mm aneurysm clip was applied successfully across the
neck of the aneurysm.
·
Haemostasis secured and wound closed in
layers.
Post
op Managements.
·
Elective sedation and mechanical
ventilation with IV Midazolam and IV Fentanyl for 48hrs.
·
IV Fluid 0.9% N/S 1L 8hrly for 48hrs
·
IV Rocephine 1g 12hrly
·
IV Omeprazole 40mg daily
·
IV Phenytoin 300mg at night, to be given
in 200mls of N/S for 1/52
·
IV Tramal 50mg twice daily
·
Tab Nifedipine 30mg daily
·
TabCodiovan 160.12.5mg daily
·
Tab Labetalol 200mg twice daily
·
Close neurocritical care monitoring
Post-Operative
events
On day one post operatively, she had one episode of
seizure which was stabilized and was kept sedated with IV Midazolam and IV
Fentanyl, the subdural drain was removed, she was gradually weaned off
ventilator support by entrailing oxygen via her ETT. 24 hours after, sedation
was reduced. She was noticed to have right peri-orbital swelling which
necessitated an urgent CT Brain scan. CT Brain showed the usual post op
changes, small subdural hematoma and cerebral oedema around the adjacent
frontal and temporal lobes. This was managed with adequate ventilatory support for optimal
blood gases, IV Mannitol and IV diuretic
(frusemide). Her blood pressure has been poorly controlled for which a
cardiologist was invited and antihypertensives increased. Second day post op,
she was noted to have electrolyte derangement (K-2.7mmol/l) and was corrected
using IV KCL infusion and subsequently potassium tablets.
48hrs
Post Op CT scan
Vital
signs today (15/01/2022)
·
HR- 68bpm
·
SPO2 – 98% on entrailed oxygen
at 4l/min
·
RR- 16cpm
·
BP- 184/97mmHg
Further management plans- she will remain on
neurocritical support, monitoring and care of all emerging issues until he
becomes very stable to sustain independence in the normal functioning of her systems.
16/01/23-
Endotracheal tube was successfully removed and satisfactory respiratory drive.
Main challenge of poor BP control is being addressed by the cardiologist.
19/01/2023
She has sustained clinical improvement. She is fully
conscious with a GCS of 15/15. (E-4, V-5, M-6) and has commenced oral sips. Blood
pressure is now within normal limit. She is currently on face mask oxygen and
currently being weaned off oxygen. She has also commenced gentle physiotherapy.
She is still currently nursed in the intensive care unit to ensure optimal
monitoring and recovery.
Vital
Signs: 19/01/2023
PR: 86 bpm
BP: 144/85mmhg
RR: 23 cpm
Vital
signs today (24/01/2023)
PR: 78b/m
BP: 160/100mmhg
RR: 32c/m
SPO2: 97% on room air
She has been weaned of oxygen completely. Has a GCS
of 14/15 (E-4, M-6, and V-4). Currently have
frequent episodes of confusion. Blood pressure control has been mildly optimal.
Hyponatremia was noticed on last kidney function test done, she is currently on
dietary salt supplementation, also being managed for urinary tract infection.
She is still nursed in the ICU to ensure proper monitoring and management.
Vital
signs: (26/01/2023)
PR: 90B/M
BP: 170/100
mmHg
RR: 30C/M
SPO2: 96% RA
Noticed to have developed significant polyuria. Has made about 11,650mls of urine in the last
24hrs. She is currently on free water and IV fluids to replenish loss. All
diuretic drugs have been stopped. Still not oriented in time, place and person.
She is still on close neuromonitoring in the ICU.
Update
(31/01/2023)
Currently, she has been discharged from the
intensive care unit (ICU) to the High Dependency Unit (HDU) on account of
improvement in her clinical state, as evidenced by resolution of previously
noted confusion, GCS presently is 15/15 and she is off all supplementary support.
She is currently having Neuro-rehabilitative physiotherapy and is marking good
progress as she now sits out of bed and stands with support during
physiotherapy. Previously noted polyuria is also resolving, urine output in the
last 24hours is 5200L and electrolyte imbalance has been successfully
corrected. However, there has been a poor blood pressure control since
admission. We are recommending that she gets an extensive review from a
cardiologist.
Vital
signs today (31/01/2023)
BP: 160/90mmHg
PR: 86bpm
RR: 18cpm
Update
(01/02/2023)
22days post microsurgical clipping of right PCOM
Aneurysm. She suffered initial post op cerebral edema associated with mild
hematoma and was subsequently managed.
Currently she is much alert with a GCS of 15/15 (E-
4, V-5, M-6) and moving all four limbs.
Recovery is satisfactory. She is making sustained
progress with Neuro-rehabilitative physiotherapy as she is standing with
support and sitting out of bed. We are currently awaiting Cardiologist review
today on account of poor blood pressure control.
Vital
signs today (01/02/2023)
BP: 170/110mmHg
PR: 110bpm
RR: 22cpm
PLAN:
·
Remove catheter
·
Continue
physiotherapy
Update
(03/02/2023)
Cardiologist reviewed her antihypertensive
medication. The dose of valsartan was increased to 160mg B.D. She is still on
regular physiotherapy and has been weaned off urinary catether. Vitals are
stable.
Update
(06/02/2023)
26days post microsurgical clipping of right PCOM
Aneurysm. The right 3rd nerve palsy-ptosis and mydriasis and all
extraoccular muscles except lateral rectus and superior oblique still
persisting otherwise she is stable. Fever has subsided following treatment of malaria
parasite. She sits out of bed. Although
occasionally confused but generally stable. She is being worked up for
discharge to continue recuperation at home (for possible discharge).
Update
(07/02/2023)
27days post microsurgical clipping of right PCOM
Aneurysm. Occasional fever spikes, but
blood pressure is better controlled. Currently on tabs Nifedipine 20MG daily
and Tabs Valsartan 80mg daily.
FBC Today: WBC-6.40, PCV-26.5, PLT- 162
EUCR: Na- 134.2, K+- 3.34, Urea- 70.60, CL- 118.5,
HCO3- 17.18, Cr- 0.79, Cal- 2.22
Urinalysis: Deep amber and cloudy, Ph- 5, specific gravity:
1.030
Vital
signs today (07/02/2023)
BP: 120/80mmHg
PR: 128bpm
RR: 22cpm
Temp: 38.2 OC
SP02: 99%
Plan:
·
CT I.V
antibiotics for another 24hrs.
·
CT Supp
diclofenac 50mg for 24hrs.
·
To transfuse
2pints of blood.
·
Adequate fluids
intake at least 3liters/ day.
·
Potassium
containing diet (banana and okro).
·
Check CT brain
Update
(07/02/2023) 4:12pm
Patient seen, 27days post op had pterional
crianotomy in micro surgical clipping of right sided PCOM aneurysm 27days ago.
She was initially managed in ICU and later transferred to the ward for
condition to stabilize. She was noticed to have temperature spike yesterday
with 39.40c.fever pattern is intermittent . MP done was positive. FBC done
showed severe anemia Hb 7.3, pcv- 26 .50. Electrolytes showed mild hypokalemia
K- 3.34. Other parameters essentially normal.
Assessment
:
·
Malaria with background anemia
·
Disselectrolytemia ( hypokalemia)
Plan:
1. Add 20mmol in 500mls 5% D/S 500mls 12hrly x 3/7
2. Commence tabs ACT 1 b.d x3/7
3. Suppository Diclofenac 50mg 8hrly x 3/7
4. GXM 3units of blood, but one pint daily under
furosemide cover over 4-6hours
5. After second pint , do post transfusion PCV before
the 3rd pint
6. I.V
furosemide 20mg start before each transfusion
7. Add 5cc Bicomplex to each 500mls of Dextrose saline
8. CT physiotherapy
Update (30/01/2023)
44yrs old female, 20days
post craniotomy for PCOM aneurysm clipping. Blood pressure is controlled heart
rate fluctuating. Current condition is still confusion.
Fluid Input/Output =
4800/5650 = -850.
Current receiving
physiotherapy.
O/E GCS – E4, M6, V4 = 14/15
(Alert, moves all limbs, weak).
PR- 117per min, BP-
118/68mmhg, RR- 25cpm
No enough confidence to sit
out of bed unaided, swallowing is sub-optimal, having issues swallowing
medications.
Assessment: Impaired
Plan:
Step down from ICU to female
ward
Continue intensive
physiotherapy
Do FBC, EUCR today.
Update (09/02/2023)
Patient seen, still having
temperature spikes last was 36.70c and hypertension BP- 160/100mmhg.
Plan:
Tabs Valsartan 160mg b,d
Continue Tabs 30mg daily.
Update (13/02/2023)
Patient is sitting out of
bed.
Blood pressure still not in
control
Plan: Continue
management
Update (17/02/2023)
Patient seen, Sits out of
bed at will.
Blood pressure control
improved.
Getting ready for discharge.
Update (22/02/2023)
Still having irrational talks
and amnesia.
Blood pressure control
suboptimal but improving.
Plan: For neuropsychiatry review
Update (22/02/2023)
Patient seen, sitting of
bed. Eating, with remarkable improvement.
Complaining of poor night
sleep. Blood pressure now over systolic of 160- 150
Assessment: Improving
Plan: Tabs Lexotan 3mg nocte
x3/7
Continue other antihypertensive
Sincerely Yours,
Dr. Halima
Ibrahim
For Team Wellington Neurosurgery WCA