26th January 2023.
TO WHOM IT MAY CONCERN
DISCHARGE
SUMMARY
A. B, 46 YEARS, MALE, WCA/6004/2023
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
Operative
Findings
·
Thickened discolored Dura
·
Dark/chocolaty chronic subdural bloody
collection under considerable pressure pushin brain to contra lateral side
·
Underlying pia/arachnoid found to be
pulsating
Operative
Procedure-
·
Under GA + LMA
·
Sterile cleaning & draping
·
Placed supine position with head to contra
lateral side exposing fronto-patietal region
·
Frontal and parietal borehole made
·
Above findings noted.
·
Dura excised to release CSDH under
pressure
·
Adequate irrigation
·
Wound drain was placed.
·
Wound closed in layers with vicryl 2/0
and staples
·
Immediate Post op satisfactory
Post
op Management.
·
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 Phenytoin 1G in 250mls of N/S stat
and then 300mg nocte for 2 days
·
Commence oral sips when fully awake
Immediate post operative period was uneventful.
Drain was taken out 48hrs post op and opening sutured airtight.
He completed his 48hrs dose of IV antibiotics and
was commeneced on tabs zinnat 500mg twive daily for 5 days.
Brain CT done 48 hrs post opp showed resolved chronic subdural hematoma with mild pneumoceplaus. See image below.
He developed subgaleal hematoma 3days post opp and
was commenced on Tab Furosemide 20mg dly, Tab Chymoral I bd.
Discharge
Instructions and Medications:
·
He will continue tab Zinnat 500mg bd x
1/52
·
Tab Vit C 1G dly x 2/52,
·
Tab PCM 1g tds x 5/7
·
Tab Dexamethasone 2mg bd x 2/7, then 2mg
dly x 1/52, then 2mg alternate days for 1/52
·
Tab Chymoral I bd x 5/7
·
Tab Furosemide 20mg dly x 5/7
·
Alternate day wound dressing
He
would be reviewed again in 4 weeks,
Please revert,
if need be, for further clarification
Sincerely,
Dr
Halima Ibrahim MD
For Team Wellington Clinics Abuja