DEPARTMENT OF CLINICAL NEUROSCIENCES

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.

SOURCE AND RELIABILITY

Patient and patient’s common law wife with good reliability

CHIEF COMPLAINT
s/p Hemicraniectomy

HISTORY OF PRESENT ILLNESS

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

PAST MEDICAL HISTORY

(+) Mumps
(+) Malaria
(2014) Motor Vehicle accident - Craniectomy
(2018) Gouty Arthritis

FAMILY HISTORY
(+) Asthma
(-) Heart disease, cancer, DM, arthritis

SOCIAL HISTORY
<1 year pack-year smoker
Alcohol dependence
Illicit drug use, stopped 2014

PHYSICAL EXAMINATION ON ADMISSION

GENERAL SURVEY Awake, alert, and not in cardiorespiratory distress
VITAL SIGNS 130/80mmHg > 66 bpm > 14 cpm > 36.7 ⁰C > 96% SpO2 at room air
Anicteric sclerae, pale palpebral conjunctiva, no tonsillopharyngeal congestion, no cervical lymphadenopathy, with left fronto-parietal cranial
HEENT
deformity, Lower lip ulcer
CHEST AND LUNGS Equal chest expansion, no retractions, clear breath sounds, no rhonchi, no adventitious breath sounds
CARDIOVASCULAR Adynamic precordium, tachycardic, with regular rhythm, distinct S1 & S2, no murmurs
ABDOMEN Round soft abdomen, normoactive bowel sounds, tympanitic, no tenderness, Surgical scar and mass on the left lower quadrant.
No obvious deformities, CRT less than 2 seconds, (-) edema, (-) cyanosis, left-sided weakness of the upper and lower extremities, Right ankle
EXTREMITIES
tenderness and right foot swelling.
F: Awake, alert, coherent, follows commands, good judgement
P: No finger agnosia, acalculia, agraphia; (+) L-R disorientation
T: Intact immediate, recent, remote memory; oriented to person and place and time
O: Able to identify 3 objects and colors

CN I: able to identify smell

CN II: Intact visual fields, (+) visual threat
NEUROLOGIC CN II, III: 2-3 mm pupils, equally and briskly reactive to light, no RAPD
CN III, IV, VI: primary gaze midline, intact and full extraocular movements
CN V: No sensory deficit on V1-V3; good masseter and temporalis tone
CN VII: No facial assymetry
CN VIII: Intact gross hearing
CN IX, X: Midline uvula, symmetric palatal arches, intact gag reflex
CN XI: Good shoulder shrug, able to turn head from side to side
CN XII: Midline tongue, no atrophy or fasciculation

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 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

Reference 6.23.18 6.26.18

BUN 3.2-6.8 4.6
Creatinine 44-106 114 100
Blood Chemistry
Sodium 135-155 144 140
Potassium 3.5-5.3 3.6 4.1

Test Reference 06.23.18

Range
Protime 10-13 11.4
Control 12.0
Bleeding Parameters INR 0.95
% Activity 95.9
PTT
APTT 29-34 27.4
Control 30

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
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  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.

COURSE IN THE WARDS

June 23, 2018 Patient was admitted under the service of Dr. Tan as a case of fronto-parietal deformity s/p hemicraniectomy. CBC with blood typing, PT/PTT, Serum sodium,
Day of Admission potassium, BUN, Creatinine, 12-L ECG and chest x-ray. Patient was allowed regular diet, ambulate and sit on a chair. Consent for procedure was secured.

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.

PHYSICAL EXAMINATION UPON DISCHARGE

GENERAL SURVEY Awake, alert, and not in cardiorespiratory distress
VITAL SIGNS BP:140/90 HR: 76 RR: 18 O2Sat: 97% at room air
HEENT Anicteric sclerae, pink palpebral conjunctiva, no tonsillopharyngeal congestion, no cervical lymphadenopathy
CHEST AND LUNGS Equal chest expansion, clear breath sounds, no rhonchi, no adventitious breath sounds
CARDIOVASCULAR Adynamic precordium, normal rate and regular rhythm, distinct S1&S2, no murmurs
ABDOMEN Flat abdomen, normoactive bowel sounds, tympanitic, no tenderness, no masses
EXTREMITIES Full equal pulses, no obvious deformities, CRT less than 2 seconds, no edema, no cyanosis
F: Awake, alert, coherent, follows commands, good judgment and insight
P: No right to left disorientation, finger agnosia, acalculia
T: Intact immediate, recent, remote memory; oriented to person, place and time
O: Can identify familiar objects and colors

CN I: able to identify coffee

CN II: Intact visual fields, no visual field cuts
CN II, III: 2-3 mm pupils, equally and briskly reactive to light, no RAPD
CN III, IV, VI: primary gaze midline, intact and full extraocular movements
CN V: No sensory deficit; good masseter and temporalis tone
CN VII: No facial palsy
CN VIII: Intact gross hearing
CN IX, X: Midline uvula, symmetric palatal arches, intact gag reflex
CN XI: Good shoulder shrug, able to turn head from side to side
NEUROLOGIC CN XII: Midline tongue, no atrophy or fasciculation

Motor:
5/5 5/5

5/5 5/5

Sensory: 100% bilaterally

Cerebellar: No nystagmus, dysdiadochokinesia, dysmetria

DISCHARGE INSTRUCTIONS

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Home Medication:

Residents-In-Charge Clinical Clerk-In-Charge

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