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NARAYANA SUPER SPECIALITY HOSPITAL

Chintareddypalem, Nellore – Ph. 0861-2317963 A.P India.


Department of NeuroSurgery

DISCHARGE SUMMARY
Name: Venkata Narasaraju P Age/Sex :64y/m Ward: Neurosurgery-ICU
Reg no: 20180213144 IP no :180205497
Date of Admission :05/02/2018 Date of Discharge: 10/02/2018
Consultant: Dr. Sai Kiran Date of surgery:25/1/2018,5/2/2018
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DIAGNOSIS:RECURRENT RIGHT FTP ACUTE ON CHRONIC SDH
History:
This 64yrs old male patient presented to emergency with complaints of weakness of left upper
and lower limb and slurring of speech from 2 days, h/o urinary incontinence from 2 days.
Past h/o fall at home few days ago.
Past h/o epilepsy and he so on Tab Eptoin, Levera and Tab Frisium
Past h/o ? CVA and patient was regularly taking Tab Clopidogrel 75 mg OD
Examination:
HR: 80min, BP: 110/70 mm/hg
Patient is drowsy and disoriented, GCS:E4V2M6
Pupils-B/L pseudophakia
Motor-Tone& bulk- normal , , paucity of left upper and lower limb movements noted
Sensory examination-Responding to pin stimuli.

Lab Investigations
Haemoglobin-10.2mg/dl TLC-16500, Neutrophils-83, Lymphocytes--10, Eosionphils-01,
Monocytes-06,Basophils-00, ESR—mm/1hr, Plateletcount-2,86,000,sodium-134meq/L
Potassium-4.4,meq/L,Chloride-92 meq/L, Serum urea-16mg/dl, Creatinine-0.79mg/dl,
PT(prothrombin time)-15.2,PT Control-13.4,INR-133,APPT-23 sec ,APPTT Control-28.0sec,
PCV- 39% vol, Blood Group-A Positive
HIV,HBS Ag, HCV- Non reactive.

Radiological Investigations

CT Brain: s/o Right FTP chronic SDH

Therapeutic procedure-1. patient underwent right frontal and right parietal burr holes and
evacuation of acute on chronic SDH ON 25/01/2018.
1
2. patient underwent reexploration via the previous burr holes and evacuation of recurrent acute
on chronic SDH ON 5/02/2018

Intra op findings
Brain was atrophied and did not reach upto the surface even after evacuation of the bleed.

Course in the Hospital; Patient underwent right frontal and right parietal burn holes and
evacuation of acute in chronic SDH ON 25/01/2018. Post operatively treated with antibiotics,
analgesics,antiepileptics,neuroprotective drugs.After 5 days in post operative period as patient
was becoming more drowsy, repeat CT Brain was done which was suggestive of recollection at
the previously operated site.Hence again surgery was performed. Hospital stay uneventful.

Condition at the Time of Discharge; Patient is conscious,obeying commands.Power 4/5 in all


limbs,mobilized on wheel chair.

Treatment Advised
Regular physiotherapy n mobilization of the patient
RT feeds 200 ml 2nd hourly
Tab Taxim-O 200mg 1-0-1 for 5 days
Tab Pantop 40mg OD 1-0-1 for 5 days
Tab Levipli 500 mg 1-0-1 to continue
Tab Eptoin 100 mg 1-1-1 to continue
Tab Frisium 0-0-1 to continue
Review in Neurosurgery OPD after 10 days

Consultants Senior Resident


Dr. Sai Kiran NA Dr.Ninad Shrikhande
Dr. Kiran Kumar VA Dr. Jatinder Mittal