MEDICAL REPORT/ DISCHARGE SUMMARY
S.K, 36YRS MALE
Diagnosis:
POLYTRAUMATIZED PATIENT WITH ACUTE SUBDURAL HEMATOMA AND RIGHT TIBIA FRACTURE
Operation Performed: CRANIOTOMY
FOR EVACUATION OF CHRONIC SUBDURAL HEMATOMA.
Date of
operation: 17th May, 2023
Background
history and presentation
The above named patient is 36yr old man who was referred from Royal orthopaedic hospital on account of reducing level of consciousness, focal seizures and right fibia fracture for six days following RTA.
He was in his usual state of health until six days ago while crossing the road when he was suddenly hit by a tricycle following which there was a transcient loss of consciousness and sustained injuries to his head, shoulder and right tibia fracture. He was subsequently rushed to National hospital where he was managed and later referred to ROH (Royal orthopaedic hospital). There was associated vomiting of recently ingested meals , reducing level of consciousness and weakness of left upper and lower limbs. There is associated right tibia fracture, which has been stabilized with crepe bandage. He was started on IV medications; antibiotics and anticonvulsant. He had a back slab on his right tibia.
Significant history of smoking and alcohol consumption
Neurology
examination findings: His pupils are 5mm on the
left and 3mm on the right, reactive. GCS-11/15 E-4, M-5, V-2.
Imaging
CT Scan of the brain revealed a Right
frontoparietal subdural hematoma with effacement of ipsilateral lateral ventricle.
Based on the above findings, the above
diagnosis was made and discussed with patient. Consent was gotten
Pre- op
Management
·
FBC – WBC- 7.29, PCV- 39%, PLT- 259.
·
E/U/Cr – Na-134.9, K- 3.26, Ur- 26.8,
Cr- 0.09.
·
Clotting Profile – APPT- 12.3s, PT-19.8s,
and INR-1.5.
·
Serology – Non reactive for HIV1&2,
VDRL, HCV and HbsAg.
·
Brain CT- showed Right
temporal parietal subdural hematoma with effacement of ipsi- lateral ventricle.
·
IVF N/S 1L 8hrly
·
Nurse 30degrees head up
·
IV Phenytoin 300mg nocte X 5/7
·
IV Midazolam 5mg stat
·
IV Mannitol 300mls over 20mins
·
IV Ceftriaxone 1g 12hrly
·
IV PCM 1g 8hrly
·
IV Omeprazole 40mg daily
·
DVT Prophylaxis – TED stockings applied.
·
Informed consent taken.
Operative
Findings
·
Clotted subdural hematoma measuring
about 75mls
·
Pulsatile brain post- evacuation of
hematoma
Operative
Procedure-
·
Under GA + ETT
·
Patient in ssupine position with right
temporal scalp facing up
·
Routine cleaning and draping done
·
Right fronto temporal question mark
scalp incision made and developed to the pericranium
·
Pericranium harvested and preserved in
saline
·
Craniotomy effected using craniotome and
gigli saw
·
Durotomy made
·
Above findings noted
·
Hematoma evacuated
·
Hemostatsis secured
·
Augmentating Duroplasty done using
pericranium
·
Bone flap replaced and secured loosely
·
Wound closed in layers over an epidural
drain
·
Sterile wound dressing applied
Post op
Management.
·
IVF O.9% N/S 1L 8hrly
·
IV Rocephin 1g 12hrly
·
IV Phenytoin 300mg nocte (in 200mls of
N/S over 30mins)
·
IV PCM 600mg 8hrly
·
IV Omeprazole 40mg OD
·
Elective sedation + mechanical
ventilation x 24hrs
·
IV 20% Mannitol 250mls 8hrly x 2doses
(to commence 8hrs pot- op)
·
Monitor vital signs closely
Immediate post operative period was uneventful.
UPDATE
(17/05/2023)9DPO
Patient seen, 9hrs post op . patient said to have occasionally wake up and restless while awake. Also has had several episodes of seizures when out of sedation. Otherwise stable.
Vital signs are stable too.
Significant history of smoking and alcohol consumption
Assessment: improving
Plan:
1. Tabs keppra 500mg 12hrly
2. Tabs Vitamin BCO 5mls to each 500mls of Normal Saline
3. Continue sedation for the next 24hrs
4. Keep in view Haloperidol if patient become more aggressive
5. Discuss with relations to make sure drugs are purchase for optimal outcome
6. IV Tramadol 50mg 8hrly
UPDATE 19/05/2023
Check Brain scan shows evacuation of previously noted right subdural hematoma with expansion of brain tissue and restoration of previously compressed right lateral ventricle. Other post surgical changes also noted.
Clinically, patient’s GCS has remained 15 in the past 48hrs and he is moving all limbs except the right lower limb that has the fracture.
Plan:
· To return to referral hospital (royal orthopedic ) to continue orthopedic management
· To remove the wound drain before transfer.
Please note that focal seizures are still present but reduced in frequency and he is to continue on current medications.
DISCHARGE
MEDICATIONS:
·
Tabs keppra 500mg bd x 1/12
·
Tabs PCM 1g tds x 5/7
·
Tabs Zinnat 500mg bd x 1/52
·
Tabs tramadol 50mg tds x 5/7
·
Tabs Vitamin C 1g daily x 2/52
To see us in 4weeks time for further review
and check brain scan. Appointment on Monday 19th June, 2023
Kindly
revert to us for clarifications where necessary.
Yours Sincerely,
Dr.
Halima Ibrahim
For Team Wellington Clinics Abuja.