MEDICAL REPORT/DISCHARGE SUMMARY
G. N, 78YEARS, MALE
Diagnosis; C3/4, C4/5 and C5/6 disc
degenerative disease/cord compression-cervical Spondylotic myelopathy.
Management plan; Counsel for ACDF
Date of Admission;
15/03/2023
Date of operation; 18/03/2023
Date of Discharge;
22/03/2023
Presentation and Neurology;
A 78yr old male who presented today
on account of 3yrs history of
progressive difficulty in walking, difficulty in using hands to sign, write and
button his shirt.
There’s history of progressive imbalance and frequent falling over and is currently in a wheel chair.
On examination, wasted intrinsic muscles of the hand, confined to wheelchair, Hoofman,positive,hypereflexia and hypertonia, grade 4/5-both upper limbs and 2/5 both lower limbs.
Imaging and Differential Diagnosis;
MRI C-SPINE shows multiple level disc osteophytic degenerative disease withmulti level cord compression and signal changes.
Pre-op Investigations and Informed Consent;
·
FULL BLOOD COUNT(16/03/2023); WBC-7.05, PCV-41%, PLT-173
·
EUCR(16/03/2023); Na-137, K-3.55, Urea-29.17, HCO3-23.56,
CR-0.76
·
FLP(16/03/2023); T.CHOL-366, Trig-13, HDL-31, LDL-332
·
Serology(16/03/2023); NON-REACTIVE
·
Clotting Profile; normal limits
INR-1.0
·
ECG; Left Ventricular
Hypertrophy
·
Chest X-ray; CTR-0.52
UPDATE; CARDIOLOGY REVIEW-16/03/2023
Patient seen,
78yr old man admitted for ACDF on account of cervival Spondylotic myelopathy, not a known hypertensive, had ejection systolic murmur. ECG showed ; LVH with ST depression in lateral leads. Echo shows normal LV ejection fraction, grade 1 diastolic dysfunction, mild concentric LVH, with significant sigmoid septum with systolic anterior motion of the mitral valve.
PLAN;
· Tabs bisoprolol 2.5mg daily
· Ensure no significant peripheral vascular dilation leading to hypotension
17/03/2023
Comment by the cardiology noted and communivated also to the anaesthesia. He is scheduled for surgery immediately today.
Plan:
· Cross check other logistic
· Nil per oral
· Set an I.V line
· Give Dextrose saline slowly
Operative
Findings
· Calcified Disc at multiple levels especially C4/5 and C5/6
· Hypertrophied posterior longitudinal ligament tighly and inseperably adherent to the dura.
Operative
Procedure
· GA, CETT, Prone, Gardner wells skull traction and shoulder traction
· Image intensifier level localization
· Standard skin prep and draping
· Standard Smith Robinson approach to the anterior cervical spine and image guided corpectomy
· Above findings noted
· Adherent PLL left alone to avoid dural and or cord injury
· End plates of C4 and C6 exposed and posterior edges undercut to fully decompress the esteophytes compressing the dura/cord
· Reconstruction performed with expandable cage
· Wound closed in layers with gravity drain
Initial
Post op Management –ICU for multimodality monitoring
· NPO till fully conscious and alert
· IVF N/Saline 500mls 8hrly
· IV Rocephin 1g 12hrly
· IV Metronidazole 400mg 8hrly
· IV Tramol 50mg 8hrly
· IV PCM 600mg 8hrly
· IV Dexamethasone 4mg 8hrly x 24hrs
· IV Omeprazole 40mg daily
· Ensure cervical collar is applied
Subsequent
Management and post op complications including check scans, bloods etc
20/03/2023
48hrs post op,
Neurology in Upper Limb > 2/5, Lower Limb 3/5
Hemodynamic stable.
General condition satisfactory.
Plan:
· convert all drugs to oral
· stop tramol
· x-ray cervical spine
· step down to the ward
Post op check CT scan of the cervical spine done;
A well place expandable cage and screws.
UPDATE (21/03/2023)
Neurology is improving. Wound is healed. He is now ambulating gradually.
Plan:
· Convert all drugs to oral
· Complete medical report
· For possible discharge
UPDATE ( 21/03/2023)
Neurology is good today. Met patient ambulating and doing well.
Plan: To be discharge today
Discharge Instructions/Medications:
·
Tabs Zinnat
500mg bd x 1/52
·
Tabs Bisoprolol 2.5mg daily
·
Tabs PCM 1g tds x 3/7
·
Tabs Flagyl 400mg tds x 1/52
·
To continue physiotherapy
·
To keep neck collar
Discharge and Follow up
·
Follow Up
visit in 2 weeks time at Wellington clinic on 5th April 2023
Kindly
revert to us for clarifications where necessary.
Sincerely yours
Dr.
Halima Ibrahim
For Team Wellington Clinics