Professional Documents
Culture Documents
Referal Summary
Referal Summary
SECTION OF NEUROSURGERY
REFERAL SUMMARY
Name Age/Sex:
Case No.:
Date of Admission:
Patient No.:
Address: Date of Discharge:
ICD Code
Attending Physician:
Admitting Diagnosis
Residents-In-Charge:
Discharge Diagnosis:
Clerks-In-Charge:.
IDENTIFYING DATA
Patient is a 33 year-old, male, single, Filipino, Baptist, farmer with no known comorbidities who came in with skull deformity s/p hemicraniectomy.
CHIEF COMPLAINT
s/p Hemicraniectomy
45 months prior to admission, the patient was involved in a motor vehicle accident resulting to head trauma, emergency left hemicraniectomy was performed at Butuan medical
center. A skull fragment was banked subcutaneously into the left abdominal area and was scheduled for cranioplasty 6 months post op. Reconstruction using the graft was deferred. In
the interim, the patient did not experience any neurological deficits, or surgical complications, but cranial deformity was still present.
At present the patient desires cranioplasty, hence consult and subsequent admission.
REVIEW OF SYSTEMS
(+) Left-sided weakness of the upper extremities
(+) Left-sided weakness of the lower extremities
(+) Slurring of speech
(+) Facial asymmetry
(+) Epigastric Pain
(-) Trauma
(-) Nausea
(-) Fever
FAMILY HISTORY
(+) Asthma
(-) Heart disease, cancer, DM, arthritis
SOCIAL HISTORY
<1 year pack-year smoker
Alcohol dependence
Illicit drug use, stopped 2014
Page 1 of 4
Motor: 5/5 on all extremities
Sensory: 100% on RUE and RLE; 100% on LUE and LLE
Cerebellar: No nystagmus, dysdiadochokinesia, dysmetria
LABORATORY WORKUP
CBC Reference 6.23.18 6.26.18
Hemoglobin 140-160 g/L 175 163
Hematocrit 40-54% 50 47
RBC 4.5-5.5 x1012/L 5.8 5.4
MCHC 32-37% 35 35
MCH 27.5-33.2 pg 30.1 20.1
MCV 80-94 Fl 86 86
RDW 11-15% 12.3 12.1
WBC 5-10 x 109/L 6.6 9.4
Differential Count
Neutrophils 37-72% 30 87
Complete Blood Count Stabs
Lymphocytes 20-50% 54 13
Monocytes 0-14% 0 0
Eosinophils 0-6% 15 0
Basophils 0-1% 1 0
Platelet 150-440 x 109/L 274 267
MPV 7.5-11 fL 9.8 9.5
Normochromic, Normochromic,
RBC morphology
Normochromic Normocytic
Chest X-ray
Clear lung fields, heart and great vessels within normal size and configuration, other chest structres not remarkable.
June 24, 2018
OPERATIVE TECHNIQUE
Date: June 26, 2018 Case No.: 0065097
Name: FLORES, Jogielito Lastra Age/Sex: 33/Male
Pre-operative Diagnosis: Left fronto-parietal post craniectomy defect secondary to head injury
Post-operative Diagnosis: Left fronto-parietal post craniectomy defect secondary to head injury
Procedure: Cranioplasty, Left fronto-parietal
Type of Anesthesia: General
Specimen: None
Surgeon: Dr. Tan/ Dr. Paez
Operation: Major Asst. Surgeon: Dr. Lazo /Lopez
Anesthesiologist: Dr. Payawal/ Dr. Reyes
Technique:
Patient placed on supine position, left side of head up under GA
Asepsis, antisepsis
Sterile drapes placed
Local anesthesia infiltrated
Linear incision made at left lower quadrant of the abdomen from previous incision
Dissection going to the bone
Bone removed
Hemostasis
Closure in layers, subcuticular skin
Page 2 of 4
Question mark incision made at left frontoparietal area from previous incision carried down to the periosteum
Skin flap dissected and retracted
Bone edges scraped to identify the dura
Dissection of dura, separated from periosteum
Bone placed using craniofix and vicryl 2.0
Bone cement placed using midas craniotore
Fixed using craniofix
JP drain placed
Closure in layers.
June 24, 2018 Patient was awake, conversant, with regard follows commands, ambulatory, no neurological deficits. Stable vitals, no untoward events.
2nd hospital day
June 25, 2018 The patient was refered to anesthesiology. 1 unit of pRBC was prepared, properly typed and crossmatched for possible OR use. Patient advised NPO 8 hours
3rd Hospital Day prior to operation. Venoclysis to started once on NPO with IVF D5NM 1L x 150 cc/hr for 4 hours then 125cc/hr thereafter. Patient consented for general
anesthesia. CBG done every 6 hours while the patient was in NPO. Given omeprazole 40mg IV once on NPO.
Patient had stable vital signs prior to operation. Patient underwent left fronto-parietal cranioplasty. Hooked to 02 at 2lpm via nasal canula at the PACU. IFV
June 26, 2018 Sterofundin x 150cc/hr given followed with pNSS x 125cc/hr after. Paracetamol 1g every 8 hours given for 2 more days. Ketorolac 30mg IV given. Tramadol
4th Hospital Day, Day of 50mg IV q6 given as needed for pain score greater than 6/10 via very slow IV push. Dolcet 1 tab q8 given for 2 days then as needed for pain to start once
operation paracetamol IV is consumed. Paracetamol 500mg/tab 1 tab q6 for 3 more days once Dolcet is consumed. Patient was encourage deep breathing. Post
operation CBC, creatinine, sodium and potassium facilitated. Ceftriaxone 1gm IV given every 12 hours. Omeprazole given 40 mg IV once daily. Ice compress
placed at incision site. Head of bed elevated at 30 degrees.
June 27, 2018 Patient was awake conversant, with regard, follows commands, ambulatory. Given pNSS 1L x 150ml/hr then 125ml/r. High back rest during daytime advised
4th Hospital Day and allowed to to sit up on bed. Patient was encouraged active ROM exercises. Soft diet allowed. Ice compress placed on incision site.
June 28, 2018 Patient was awake conversant, with regard, follows commands, ambulatory. May allowed to dangle legs. High back rest advised. Fall precautions in place. JP
5th Hospital Day drain removed.
June 8, 2018 Patient did not have other subjective complaints. Upon physical examination, the patient is afebrile with stable vital signs. He is awake, alert, conversant, and
6th Hospital Day follows commands. No new neurological deficits noted. Patient was scheduled for discharge.
Motor:
5/5 5/5
5/5 5/5
DISCHARGE INSTRUCTIONS
Page 3 of 4
Home Medication:
Page 4 of 4