01/05/2023
Medical Summary:
M.M 54yr, Male
Diagnosis:
Normal Pressure Hydrocephalus (NPH)
Management
Plan:
·
Lumbar drain insertion for (CSF
tap test)
·
For VP shunt insertion if above
is positive
·
Tabs neurobion 1 daily x 4/52
Presentation
and Neurology:
The above named patient is 54yr old with
background history of hemorrhagic stroke intraventricular treated non –
operatively one year ago. Known but poorly controlled hypertensive and
diabetic.
Presented today accompanied by family on
account of progressive cognitive decline, memory lapses, gait imbalance and
occasional urine incontinence.
Neurological examination essentially less
defective affect.
Fundoscopy shows blurring of the cup disc maging.
Neuroimaging
and Diagnosis:
Brain
MRI showed dilatation of the lateral ventricles
with periventricular hyperdensities (evidence of long standing hydrocephalus
and CSF slippage)
UPDATE
30/08/2023
A 54yr old man with background history of
hemorrhagic stroke intraventricular treated non – operatively one year ago. He
is a known patient of our facility and he is being worked up for VP shunt on
account of communicating hydrocephalus. Patient has been reviewed by
cardiologist and has been cleared for surgery.
However, the patient has been on aspirin
tablets, his last dose was 2 days ago prior to presentation.
Pre-operative lab investigation was all essentially
normal.
PLAN:
1.
Admit patient and continue
surgery workup.
2.
To have surgery 7 days after
discontinuation of aspirin.
OPERATION
NOTE 02/08/2023
OPERATIVE FINDINGS: clear CSF under
moderate opening pressure.
DETAILS OF SURGICAL PROCEDURE:
·
Patient is supine, G.A + E.T.T
·
Op site marked and infiltrated
with lidocaine + adrenaline and positioning
·
Routine cleaning and draping
done
·
Linear incision made on the
scalp and hemostasis secured
·
Burr hole made and dura
explored
·
Abdominal incision made 4cm
below the right costal margin and layers of the abdomen dissected, hemostasis
secured.
·
Vicryl 3/0 suture applied as a
stale suture around the peritoneal layer
·
Skin tunnelling done and it was
staged at the clavicle
·
Shunt passed and ventricular
catheter inserted into the abdomen.
·
Skin closed in layers; pechus
vicryl 2/0, subcutaneous vicryl 2/0, skin staple.
·
Sterile dressing applied.
POST-OP
Instructions
1.
IVF N/S 1L 8hrly
2.
IV ceftriaxone 1g 12hrly
3.
IV PCM 900mg 8hrly
4.
IV Omeprazole 20mg daily
5.
TED stockings.
UPDATE
03/08/2023
24 hours post VP shunt on account of normal
pressure hydrocephalus. Patient has commenced oral sips, had one episode of
vomiting.
V/S; BP- 160/100, PR- 109bpm.
PLAN:
1.
Recommence oral
antihypertensive and oral antidiabetic.
2.
Continue IV antibiotics.
3.
Continue order post-op order.
4.
To do FBC and EUCR tomorrow.
UPDATE
04/08/2023
2 days post VP shunt on account of normal
pressure hydrocephalus. Patient has complaints of mild headache and abdominal
pain (site of surgery)
Yet to pass stool, however passing gases.
O/E: conscious, in no obvious distress, not
pale, anicteric.
PLAN:
1.
Check brain scan today
2.
Convert IV antibiotics to oral
antibiotics (tabs cefuroxime 500mg bd)
UPDATE
05/08/2023
3 days post VP shunt on account of normal
pressure hydrocephalus. No fever spike. He had an episode of vomiting this
morning, otherwise fine
Check Brain CT scan revealed VP shunt in 3rd
ventricle.
O/E: conscious, not in any distress, not
pale, anicteric, acyanosed, nil pedal edema.
PLAN:
1.
For revision of cranial part of
VP shunt
2.
MP.
UPDATE
08/08/2023
48hrs post VP shunt revision. Patient was
noticed to have developed loss of appetite, also complaint of headache.
Check CT scan done (7/8/23) showed the tip
of the VP shunt is close to the septum pellicidum.
V/S: PR- 118bpm, SPO2- 96%, RR- 20cm, BP-
110/80mmhg.
Assessment:
1.
VP shunt malfunction.
2.
Dyselectrolytemia
PLAN:
1.
To do FBC and EUCR.
DISCHARGE
NOTE
Patient is currently being managed for mild
hyponatremia. Patient is to be discharged home today.
Abdominal sutures have been removed but
some of the cranial sutures are still in situ.
PLAN:
1.
Discharge home today
2.
ORS 1L 24hrly x 2/7
3.
Tabs amlodipine 10mg dly x 1/12
4.
Tabs valsartan 80mg bd x 1/12
5.
Tabs indapamide 1.5mg dly x
1/12
6.
Tab vit Bco idly x 1/52
7.
Tabs glucophage 1g bd x 1/12
8.
Tabs glimepiride 4mg bd x 1/12
9.
Tabs Zinnat 500mg bd x 5/7.
See patient in 1 week to remove remaining
sutures.
Kindly revert for further clarifications if
need be.
Sincerely Yours,
Dr. Halima Ibrahim
For Team Wellington Clinics
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