NAME : DIL JEHAN

REF :155789/004
DATE :29/11/2017
ULTRASOUND ABDOMEN
CLNCAL SUMMARY.Mr.KAMALKUMARIP.NO.9180T.
Diagnosis: TRAUMATIC BRAIN INJURY WITH HEMORRHAGIC CONTUSIONS RIGHT FRONTO
TEMPOROPARIETAL-REGION STATUS POST DECOMPRESSVE CRANIOTOMY-1
TRACHEOSTOMY
ICU CLINICAL SUMMARY: This 55 years old woman was brought to the Emergency on
29/11/2017 following a sad incident of slipping leg in washroom resulting a hard head injury
and became unconscious. In the ER her GCS was 11/15 and vital signs were not stable. She was
admitted to the ICU for close monitoring and treated with antiedema measures, seizure and
DVT prophylaxis.
A repeat CT scan after 48 hours showed the hemorrhagic contusion in the right frontoparietal
region of skull with significant mass effect. Clinically, there was left hemiplegia. Repeat CT brain
showed the features of increase ICP with midline shift. She required emergency decompression
craniotomy. The neurological damage is very high. The antibiotics were continued
Percutaneous tracheostomy was created for airway management. Given the severe traumatic
brain injury including the need for decompressive craniotomy, he will required hospitalization
for a further period of at least 4 weeks.
Dr. jawad s khan
Consultant Neurosurgeon
Department of Neurology