08th
March, 2023
MEDICAL
REPORT
U.A , 46 YEARS, MALE
HOSP
NO: WCA/6064/2023
Operation- Burr hole + evacuation of CSDH
Date of Admission- 03/03/2023
Date of Operation-
04/03/2023
Background
Information:
A 46yr old man who was referred on account of worsening headache following trauma to the head x 4/52, an episode of vomiting and altered sensorium of 1/52
Examination: Conscious, GCS 14/15. Normal Power, tone and reflexes on both upper and lower limbs. Gait is unsteady
Pre-operative
Planning:
·
For burr hole evacuation
·
Admit patient
·
Secure I.V access
·
I.VF N/S 1L 8hrly
·
I.V PCM 600MG 8hrly
·
I.V Tramadol 50mg 12hrly (withhold)
·
Counsel patient on his pathology
·
Get informed consent for surgery ASA
logistics is sorted
·
FBC, EUCR, Clotting Profile, serology
·
Withhold sedative and analgesics
·
Neck X-ray
·
ECG, Chest X-ray
Lab
investigations findings:
FBC- Within the normal
limit ( PCV- 44%, WBC: 6.39, PLT: 250)
EUCR- within the normal
limit ( Na- 141.1, K: 3.81,Ca: 2.34, Cr: 1.06, Urea: 28.50)
Clotting Profile- INR:
1.1, , PT: 14.8 sec APTT: 50.0sec
Serology : ALL Non-
Reactive.
Pre-Operative
Imaging
Right convexity Isodense chronic subdural hematoma with mass effect- midline shift and effacement of right lateral ventricles
Operative
Findings:
·
Crank oil-colored subdural collection
under pressure
·
Pulsating brain post- evacuation
Operative
Procedure:
· Under GA +LMA
· Patient laid supine with right frontal scalp facing up
· Routine cleaning and draping done
· Right frontal scalp incision made and developed to the pericranium
· Hemostasis secured
· Burr hole made using craniotome
· Dura cauterized
· Evacuate Durotomy made and dural edges cauterized
· Above findings noted
· Hematoma evacuated
· Copious irrigation done with saline
· Subdural drain placed with size 12F foley catheter
· Wound closed in layers
· Sterile wound dressing applied
Post-
op management:
·
IVF
0.9% N/S 1L 8hrly x 24hrs
·
I.V
Rocephin 1g 12hrly
·
I.V
PCM 600mg 8hrly
·
I.V
Tramadol 50mg 8hrly
·
I.V
Phenytoin 1g stat ( in 200ml of N/S to run over 30mins )
·
I.V
Omeprazole 40mg O.D
·
Allow
oral feeding when fully out of anesthesia
·
Commence
tabs keppra 500mg BD the following day
·
Monitor
vital signs closely
Update (06/03/2023)
2days
post burr hole evacuation of subdural hematoma. He passed through a phase of
restless or irrational talks which was compound to be due to post op pneumocephalus
which was found in check CT scan. Drain was removed and stoma tightly sutured
with 2.0 nylon. Oxygen face mask for 24 hrs was deployed to treat the
pneumocephalus and the restlessness was observed to have abated in the next 24
hrs
This
morning, he is fully conscious, calm, GCS- 15, Pupils- normal reacting to light
and moving all four limbs
BP-
130/90mmHg, SAT- 100% in RA
Plan:
·
To
step him down to ward
·
Continue
monitoring
·
Change
antibiotic to oral for the next 3days.
Update (08/03/2023)
Neurologically
stable but suffered one episode of headache. Reasonably fit for discharge
Discharge Instructions
·
Alternate
day dressing
·
Outpatient
follow up and Remove stitches/clips after a week 14/3/2023
·
Tab
Zinnat 500mg bd for one week
·
Tab
pcm 1 g tds for 5 days.
·
Tab
Vit C 1000mg daily for a week
·
Tab
Dexamethasone 2mg tds 3 days, the 2mg bd 3 days then 2mg daily 3 days the 2mg
alternate days
·
Tab
Omeprazole 20mg daily 1 week.
Please
revert for any further clarifications
Sincerely
Yours
Halima
Ibrahim MBBS
For
team Wellington Clinics Abuja
---------electronically
signed to prevent delay in transmission.