DISCHARGE
SUMMARY
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.
Imaging
·
Pre-operative CT brain showed left chronic subdural hematoma with
a midline shift
26 Jun, 2023