4th July, 2023
MEDICAL
REPORT
O.A /34YEAR/ MALE
DIAGNOSIS:
Degenerative
disease of cervical spine
BACKGROUND
HISTORY AND PRESENTATION:
The above named
patient is 34yr old man who presented weakness in his upper and lower limbs
4yrs ago, more severe on the left side. There is also associated tremors,
numbness and parathesis, which is worse on the left side of the body. He has
difficulty in writing or buttoning of shirt. No radicular pains. No associated
history of urinary and fecal incontinence. He is not a known hypertensive/
diabetic.
NEUROLOGY:
Normal tone, power
in all limbs, hyperreflexia noted on all limbs globally
NEURO
IMAGING
MRI Cervical spine
below C4/5 degenerative spine disease.
MANAGEMENT
PLAN:
1.
Admit
patient and work up for C4/5 ACDF
2.
GXM
2 units of blood.
Pre- Operative
evaluation (05/07/2023)
FBC: WBC- 3.93,
HCT- 39.34, PLT- 172
EUCr: Na- 142.9,
K- 3.44, Ur- 44.10, Cr- 1.28
Clotting profile:
PT- 12.5secs, INR- 0.9, APTT- 32.2secs
Serology: Non-
reactive
Informed Consent
Obtained.
OPERATION
NOTE 12/07/2023
INTRA-OPERATIVE:
1.
C4/5
herniated disc
2. Hypertrophied PLL
3.
Saucerization
of the cord of the C4/5 level
DETAILS OF
SURGICAL PROCEDURE:
·
Patient
supine; GA + ETT
·
Incision
site identified, shaved and infiltrated with lidocaine adrenaline
·
Siting
was applied via a garderner’s well traction and counter traction applied via
the upper limb bilaterally.
·
Routine
sterile cleaning and draping applied
·
Incision
made through the skin crease and with electrocutery device, hemostasis secured
and blunt dissection done.
·
Trachea
and oesophagus retracted to the right, the sternocleidomastoid muscle and
carotid sheath retracted to the left.
·
Longus
colli muscles identified and stripped off
·
Intra-op
identification done
·
Tram-hive
retractors applied and disectony done with corresponding implant (size 8) inserted.
·
Drain
applied and closure in layers, with a subcurticular skin closure with vicryl
3/0.
POST-OP
INSTRUCTIONS
1.
IVF
N/S 1L 8hrly
2. IVF GKI
3. IV rocephin 1g 12hrly
4. IV tramadol 50mg 12hrly
5. IV Omeprazole 20mg daily
6. IV Dexamethasone 4mg 8hrly x
24hrs
7. Fluid input/output chart.
8. RBS check
9.
Keep
rigid collar in-situ for 2 weeks.
UPDATE 13/07/2023
A 34years old
male, who had a C4/5 ACDF done 24 hours ago on account of C4/5 disc herniation
and cord compression. Patient had severe hypoglycemia yesterday, post surgery
was adequately controlled. However, still having rebound hypoglycemia.
Drain had a
minimal discharge and has been removed.
FBS: 1.8mmol.currently,
still on 5% dextrose saline correction.
PLAN
1.
Inform
anesthetist about development
2.
Continue
management.
UPDATE 17/07/2023
A 34years old
male, who had a C4/5 ACDF done 4 days ago on account of C4/5 disc herniation
and cord compression.
No longer having
pains on the limbs, moving all limbs. Blood pressure has been elevated despite
being on tab amlodipine 10mg, tabs telmisartan 80mg. white blood cells
elevated, PCV 30%. However, there is no fever.
O/E: conscious,
mildly pale, anicteric, acyanosed.
Vital signs: BP
190/90mmHg (before antihypertensive) 160/120mmHg (after tabs amlodipine)
Wound: clean and
dry
PLAN
1.
Change
to tabs nifedipine 30mg dly
2. Tabs Zinnat 500mg 12hrly x 1/52
3. Tabs metronidazole 400mg 8hrly x
1/52
4.
Tabs
tramadol 50mg 12hrly x 1/52.
DISCHARGE SUMMARY
A 34years old
male, who had a C4/5 ACDF done 5 days ago on account of C4/5 disc herniation
and cord compression.
Patient is
currently doing well, blood pressure fairly controlled today (140/80mmHg).
Ambulating
efficiently, wound is clean and dry.
PLAN
·
Discharge
home today
·
Continue
neck collar for 2 weeks
·
Tabs
nifedipine 30mg dly
·
Tabs
Zinnat 500mg 12hrly x 1/52
·
Tabs
metronidazole 400mg 8hrly x 1/52
·
Tabs
tramadol 50mg 12hrly x 1/52.
·
Tabs
HCT 50mg dly x 1/12
·
Tabs
telmisartan 80mg bd x 1/12
·
Syr.
Astymin10mls bd x 2/52
·
Tabs
pregabalin 75mg dly x 1/52
See in 2 weeks (01/08/2023) for out-patient follow up.
Kindly revert to us for further clarifications where necessary.
Yours Sincerely
Dr. Ozoemena O.F
For team wellington clinics Abuja.