9th Februrary, 2023.
TO WHOM IT MAY CONCERN
MEDICAL
REPORT
O.C.G 39 YEARS, MALE
WCA/6020/2023
Diagnosis: LEFT SUBACUTE SUBDURAL
HAEMATOMA
Operation Performed-
LEFT BURRHOLE CRANIOTOMY FOR EVACUATION OF SUBACUTE CRANIOTOMY.
Date of operation-
08/02/2023
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, inability to talk of 4 days duration and 3 episodes of
seizures.
He was in his usual state of health until about 3 weeks
prior to presentation when he was involved in a RTA. Following the RTA he
started having headaches which were gradually worsening in intensity, no
identifiable aggravating or relieving factor, no vomiting. He had 3 episodes of
generalized tonic clonic seizures lasting about 30minutes, spontaneously
aborted, no urinary of faecal incontinence, no post ictal sleep. He has no
symptoms suggestive of hypertension or diabetes.
Neurology
examination findings -His pupils are 3mm bilaterally
reactive to light. GCS-10A/15 E-4, M-6, V-Aphasic, Normal tone, power and
reflexes in all limbs.
Imaging
· Pre-operative CT brain showed left subacute subdural hematoma with a midline shift
Based on the above findings, the above diagnosis was
made and discussed with patient. Consent was gotten.
Pre-
op Management
·
FBC – WBC-7.88, PCV- 43%, PLT- 379.
·
E/U/Cr – Na-136, K- 4.09, Ur- 39, Cr-
0.98.
·
Clotting Profile – APPT- 31.5s, PT-11.3s,
and INR-0.8.
·
Serology – Non reactive for HIV1&2,
VDRL, HCV and HbsAg.
·
Brain CT- showed left subacute subdural
hematoma
·
DVT Prophylaxis – TED stockings applied.
·
Informed consent taken.
Operative
Findings
·
Thickened discolored Dura
·
Dark/chocolaty subacute subdural bloody
collection under considerable pressure pushing 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 subacute SDH
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
·
Commence oral sips when fully awake
Immediate post operative period was uneventful.
Update
(09/02/2023)
1 day post op burr hole for evacuation of subdural
hematoma.
39yrs old man admitted yesterday and had an
emergency burr hole for evacuation of chronic subdural hematoma. He had sustained traumatic injury following bike
accident two weeks ago and developed worsened headache since then and aphasia.
Brain
CT Scan confirms left sided chronic subdural hematoma. On
admission, he was complete aphasic with right sided hemiparesis.
CT
Brain confirmed left sided acute and chronic subdural
hematoma with mass effect effacement of lateral ventricle and midline shift
following informed consent and had above operation.
Operative findings has dark chocolaty blood clot
that came out under high pressure through the frontal burr hole. But most
remarkable is the finding from the parietal burr hole which was massive
bleeding upon opening of the dura that was difficult to control which was bipo
surgi cell and bone works.
Neurology this morning shows improvement to grade 4/5
power of the right upper and lower limbs and complete aphasia has improved to
sensory aphasia. No headaches, no vomiting.
Assessment:
Good
progress
Note: the drain didn’t bring out anything
Plan:
check for Brain CT scan.
Please revert,
if need be, for further clarification
Sincerely,
Dr
Chizim Mordi MD
For Team Wellington Clinics Abuja