MEDICAL REPORT
O.E /61 YEARS/ FEMALE/
HISTORY
AND CLINICAL PRESENTATION:
A
61 year old woman who presented on the 27th of April, 2022 for
follow up presented with a complaint of scalp swelling. She is a known patient
of this facility on management for recurrent scalp masses (giant cell tumour).
NEUROLOGY
AND EXAMINATION:
Mass
size was about 4 X3 cm located at the parietal region, non tender, firm, non
rubbery, non fluctuant, not transillunimating.
INVESTIGATIONS
AND TREATMENT:
She had a brain MRI + contrast scan on the
27th of April, 2023 which revealed a soft tissue mass on the
parietal region which shows features of bone erosion with mass effect on the
brain. Excision biopsy was done on the 8th of May, 2022 which was
successful. Post operative conditions were uneventful. About 12 days after the
surgery, patient was noticed to have had a generalized tonic seizure of about 2
episodes. 1st spontaneously aborted and the 2nd one was
aborted with IV diazepam. The Neurosurgeon was informed and was placed on IV
Phenytion, IV furosemide, mannitol and diazepam. Vitals were checked.
On the 20th of May, 2022, she
was managed as a case of seizures
secondary to raised ICP. GCS examination: E-4, V-2, M-5 ; PERL, R-sided hypotonia
Repeat MRI 1.5T+ contrast was done and
revealed para-axial collection. She was reviewed by the oncologist and findings
were noted (25/05/2022) radiotherapy was done which failed. She was advised to
get Denosumab (Xgvar), do FBC, EUCr, Ca, ALP & LFT. She was placed on
Calcium 600mg and Vit D 400IU. She had been on Tabs HCT, Valsartan, Metformin,
Atorvastatin, Epilim. Six months after all previous treatment, she presented
for follow up in this facility and she reported to have had no seizures during
that 6 month period. she was advised by the oncologist to continue the Denosumab
therapy for an additional 6 months to make it a year and was to be reviewed a
month after.
She presented a month after (15/12/2022)
for follow up for recurrent osteoclastoma complicated by focal epilepsy.
Complaints was that she has become somnolent and it was attributed to the drug
Epilim which she was on. Examinations revealed RUL & LL- 4, LUL& LL- 3,
not oriented in time, aphasia improving. Medical plan was to commence Keppra,
do EUCr, TFT, Total CK, and consider repeating the imaging investigation. She
was also placed on physiotherapy.
A month afterwards, she presented to this
facility for follow up (26/1/23), she had been seizure free since last visit
but with marked rigidity. TFT & EUCr were all normal. Plan was to do a
neuroimaging due to ptosis, somnolence; continue the Keppra, reduce the dose of
the Epilim to 500mg nocte, add Elizanidine 2g b.d, continue neurorehabilitation
and come for follow up in 2 months time.
Two months
afterwards (16/03/2023), she came to this facility for follow up. She had been
seizure free since last visit. Complained of somnolence. Plan was to do FBC,
tabs bisoprolol 5mg dly, tabs fesolate 400mg b.d x 3/12, see endocrinologist,
reduce the dose of the Epilim to 200mg nocte for 2/52, then alternate days for
2/52, continue Keppra and neurorehabilitation. Requested MRI scan revealed no
new pathology, Cervical MRI was normal. Dosages of Epilim and Bisoprolol were
reduced to 3 times a week and 2.5mg dly respectively. Endocrinologist’s review
after some investigations were carried out was acceptable glycaemic control and
?subclinical hypothyroidism. Plan was to be on Galvus met 50mg/1000mg 1 b.d,
Bisoprolol 2.5mg dly, Amilodipine 10mg dly, Codoraxc 4mg dly, Co-Dirvan
160/12.5mg dly, ASA 75mg dly, Epilim 500mg 3x in a week, Calcium 600mg every
alternate day, Physiotherapy 3x weekly, follow up in 2 weeks time. 2 weeks
after, she was presented for follow up and was regular on medications and
physiotherapy. Review of systems not contributory.
Kindly
revert to us for clarifications where necessary.
Yours
Sincerely,
Dr. Motajo Modupeoluwa O.
For Team Wellington Clinics Abuja
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