Saturday, September 26, 2009
Thursday, September 24, 2009
Thursday, September 17, 2009
Left FP ASDH
Referred case from ED yellow zone
16yo malay boy
No known medical illness
Alleged MVA this morning
MB vs MB, at 7.15am near Sek Men Teknik Paya Jaras today Had LOC ? duration, regained consciousness on the way to hospital. No vomiting
No limb weakness- able to move all limbs, but noted by ED MO pt a bit restless- given sedation prior to CT brain done
No ENT bleeding
No SOB/ chest pain/ abdominal pain
o/e:
GCS E3V3-4M5 (11-12/15)
Pupils 3/3 ++
Noted multiple abrasions wound (small) over the face
Chest/ pelvic spring -ve
No spine tenderness
No obvious long bone deformity
BP 135/87
HR 90
Spo2 100% on air
Lungs: clear
P/a: soft, nontender
Moving all 4 limbs power bilateral UL/LL >4/5
Reflexes normal
CT brainLt frontal contusion with Lt frontoparietal SDH with maximum thickness 0.5cm over 10cuts MLS 0.5cm Brain edematous BS partially efface
16yo malay boy
No known medical illness
Alleged MVA this morning
MB vs MB, at 7.15am near Sek Men Teknik Paya Jaras today Had LOC ? duration, regained consciousness on the way to hospital. No vomiting
No limb weakness- able to move all limbs, but noted by ED MO pt a bit restless- given sedation prior to CT brain done
No ENT bleeding
No SOB/ chest pain/ abdominal pain
o/e:
GCS E3V3-4M5 (11-12/15)
Pupils 3/3 ++
Noted multiple abrasions wound (small) over the face
Chest/ pelvic spring -ve
No spine tenderness
No obvious long bone deformity
BP 135/87
HR 90
Spo2 100% on air
Lungs: clear
P/a: soft, nontender
Moving all 4 limbs power bilateral UL/LL >4/5
Reflexes normal
CT brainLt frontal contusion with Lt frontoparietal SDH with maximum thickness 0.5cm over 10cuts MLS 0.5cm Brain edematous BS partially efface 
Tuesday, September 15, 2009
Left FTP CSDH
REFERRED CASE FROM ED RESUS
33yo chinese man
Background problem:
1) Young HPT (diagnosed 6 years ago age 27-28 years old), last seen by medical team in July 2009 Carotid doppler done: Left ventricular dysfunction, left ventricular thrombus, left internal carotid artery occlusion- on warfarin
2) CVA with dense right side hemiplegia and global aphasia (admitted in medical in Oct 2008- had neurorehabilitation)
Patient was admitted there from 22nd October 2008 to 1st May 2009 :
Hx from brother:
Presentd with less responsive, noted by family members since 2days ago. Condition worsened as previously pt was ADL independent, eventhouigh had Rt sided hemiplegia + global aphasia- pt was still able to bath/ eating by himself. This morning noted that pt was drowsy + PU in bed
. Hence, the family members brought pt immediatly to ED. Family claimed no h/o trauma at home. Compliance to medications - but last night ? took medications (including warfarin) by himself- no eye witness on how much he took
No fitting seen
No vomiting
No SOB/chest pain
No abdominal pain
No other complaint
o/e:
Opening eyes spontaneously, on + off obeying commands
GCS E4V1(global aphasia)M5-6
Pupils 3/5 sluggish
BP 160/82
HR 100
Afebrile
Spo2 99% on air
Lungs: clear
P/a: soft, nontender
Tone: Rt UL/ LL increased, Lt normal
Noted Rt sided body hemiplegic- 0/5, Lt UL/LL >3/5
Reflexes left sided briskBabinski: bilaterally downgoing
CT brain: Lt pareital acute SDH, maximum thickness 1.3cm x 4.4cm (AP), over 10cuts MLS of 1.6cm to the right, sulci & gyri not well differentiated- ? generalize edema Lt lateral ventricles compressed- pushed to the Rt, rt temporl horn opened BC partially efface Blood ix: FBC: WCC 8.4, Hb 14.3, Plt 243 RP: U 8.8/ Na 139/ K 3.7/ Cr 86 PT/APTT: 10.8/22.2 INR: 1.15 Impression: Lt parietal acute SDH ? 2' to overwarfarinization
33yo chinese man
Background problem:
1) Young HPT (diagnosed 6 years ago age 27-28 years old), last seen by medical team in July 2009 Carotid doppler done: Left ventricular dysfunction, left ventricular thrombus, left internal carotid artery occlusion- on warfarin
2) CVA with dense right side hemiplegia and global aphasia (admitted in medical in Oct 2008- had neurorehabilitation)
Patient was admitted there from 22nd October 2008 to 1st May 2009 :
Hx from brother:
Presentd with less responsive, noted by family members since 2days ago. Condition worsened as previously pt was ADL independent, eventhouigh had Rt sided hemiplegia + global aphasia- pt was still able to bath/ eating by himself. This morning noted that pt was drowsy + PU in bed
. Hence, the family members brought pt immediatly to ED. Family claimed no h/o trauma at home. Compliance to medications - but last night ? took medications (including warfarin) by himself- no eye witness on how much he took
No fitting seen
No vomiting
No SOB/chest pain
No abdominal pain
No other complaint
o/e:
Opening eyes spontaneously, on + off obeying commands
GCS E4V1(global aphasia)M5-6
Pupils 3/5 sluggish
BP 160/82
HR 100
Afebrile
Spo2 99% on air
Lungs: clear
P/a: soft, nontender
Tone: Rt UL/ LL increased, Lt normal
Noted Rt sided body hemiplegic- 0/5, Lt UL/LL >3/5
Reflexes left sided briskBabinski: bilaterally downgoing
CT brain: Lt pareital acute SDH, maximum thickness 1.3cm x 4.4cm (AP), over 10cuts MLS of 1.6cm to the right, sulci & gyri not well differentiated- ? generalize edema Lt lateral ventricles compressed- pushed to the Rt, rt temporl horn opened BC partially efface Blood ix: FBC: WCC 8.4, Hb 14.3, Plt 243 RP: U 8.8/ Na 139/ K 3.7/ Cr 86 PT/APTT: 10.8/22.2 INR: 1.15 Impression: Lt parietal acute SDH ? 2' to overwarfarinizationHe underwent craniectomy and evacuation of clots. Intra-op FFP was transfused. Post-op he was ventilated and sedated.Sedated on IV midamorphine 5mls/hr o/e:Pupils 2/3 sluggish BP 122/88HR 102AfebrileSpo2 99% on air Noted still slowly oozing head drain site Head drain 22cc
Repeated CT brain post op noted:Reaccumulation of bleeding.
He was subjected for another operation
Post-op, he was put on sedation and ventilation support. A repeat CT scan was performed.
Repeated CT brain post op noted:Reaccumulation of bleeding.
He was subjected for another operation
Post-op, he was put on sedation and ventilation support. A repeat CT scan was performed.
Tuesday, July 7, 2009
Traumatic Extradural Hematoma
REFERRED CASE FROM HTAR
20yrs/Malay/Gentleman
No known medical illness
Alleged MVA ( mechanism of injury not known )
brought in to hospital by passerby ( Hospital Banting )
GCS upon arrival in Hospital Banting was 14/15 ( was confused )
Then pt fitted once , following which IV Valium was given - then GCS dropped to 7/15
Was intubated in Hospital Banting and sent to HTAR for CT Brain
He was treated with cerebral resuscitation and ICP monitoring. A repeat CT scan was performed on 28/6/09 showed slight increased in size of EDH, however ICP maintained below 20mmHg.
EET tube was dislodged 2 days later. He was reintubated. Repeat CT scan done.
ICP noted increased trend about 26mmHg. He was subjected for posterior fossa craniotomy.
20yrs/Malay/Gentleman
No known medical illness
Alleged MVA ( mechanism of injury not known )
brought in to hospital by passerby ( Hospital Banting )
GCS upon arrival in Hospital Banting was 14/15 ( was confused )
Then pt fitted once , following which IV Valium was given - then GCS dropped to 7/15
Was intubated in Hospital Banting and sent to HTAR for CT Brain
| PHYSICAL EXAMINATION | ||||||||
| General | : | Upon arrival in ED GCS : E1VtM5 Pupil : Pinpoint ( on IV Midamorphine ) | ||||||
| CVS | : | DRNM | ||||||
| Respiratory | : | Clear,equal air entry | ||||||
| Abdomen | : | Soft | ||||||
| Diagnosis | : | CT Brain findings ( Done at 11pm on 27/06/09 ) : Thin EDH seen at the (L) posterior fossa measuring 1.5cm in thickness x 4.5 cm ( seen over 4 slides ) + temporal contusion seen at the base of (R) temporal fossa - no midline shift - Basal cistern patent | ||||||
He was treated with cerebral resuscitation and ICP monitoring. A repeat CT scan was performed on 28/6/09 showed slight increased in size of EDH, however ICP maintained below 20mmHg.
EET tube was dislodged 2 days later. He was reintubated. Repeat CT scan done.
ICP noted increased trend about 26mmHg. He was subjected for posterior fossa craniotomy.
Tuesday, June 30, 2009
Traumatic Chronic Subdural Hematoma
Case: 67 years old Chinese gentleman, referred from HTAR on 27/6/09 with history of alleged fall at home 2 weeks and became disorientated and bed-ridden 3 days prior to admission.
He was admitted previously on 23/5/2009 when he was alleged fell at home on the same day with admission GCS of E4V2M5. CT scan done showed right frontal ICH. He underwent craniotomy and evacuation of clots and discharged home with full GCS.
On arrival his GCS was E3 V2 M5 with pupils 3+/3+.
BP 146/76, HR 76 Afebrile Spo2 100% on air Lungs: clear CVS: DRNM P/a: soft, nontender Able to move all 4 limbs but unable to assess proper power CT brain
Mixed hyp & hyperdense lesion - SDH in left frontoparietal Thickness 4cm Local mass efeect on ipsolateral ventricle & contralateral MLS BC still patent Evidence of previous Rt frontoparietal craniectomy + encaphalomalacia Rt frontal lobe Impression: chronic Lt frontoparietal SDH He underwent left parietal burrhole and drainage on 27/6/09. Post-op he is remained ventilated and sedated.
Post-op CT scan on 28/6/09
Display Pacs Report NON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.
Written Clinical Comments: post Burrhole drainage
Findings:
***No previous image in the PACS for comparison.
Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.
Impression:
ICB with midline shift.
He underwent left parietal mini-craniotomy and subdural drainage on 29/6/2009
Display Pacs Report NON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.
Written Clinical Comments: post Burrhole drainage
Findings:
***No previous image in the PACS for comparison.
Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.
Impression:
ICB with midline shift.
On POD2, he was extubated. Pre-extubation GCS E4 VT M6.
He was admitted previously on 23/5/2009 when he was alleged fell at home on the same day with admission GCS of E4V2M5. CT scan done showed right frontal ICH. He underwent craniotomy and evacuation of clots and discharged home with full GCS.
On arrival his GCS was E3 V2 M5 with pupils 3+/3+.
BP 146/76, HR 76 Afebrile Spo2 100% on air Lungs: clear CVS: DRNM P/a: soft, nontender Able to move all 4 limbs but unable to assess proper power CT brain
Mixed hyp & hyperdense lesion - SDH in left frontoparietal Thickness 4cm Local mass efeect on ipsolateral ventricle & contralateral MLS BC still patent Evidence of previous Rt frontoparietal craniectomy + encaphalomalacia Rt frontal lobe Impression: chronic Lt frontoparietal SDH He underwent left parietal burrhole and drainage on 27/6/09. Post-op he is remained ventilated and sedated.
Post-op CT scan on 28/6/09
Written Clinical Comments: post Burrhole drainage
Findings:
***No previous image in the PACS for comparison.
Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.
Impression:
ICB with midline shift.
He underwent left parietal mini-craniotomy and subdural drainage on 29/6/2009
Written Clinical Comments: post Burrhole drainage
Findings:
***No previous image in the PACS for comparison.
Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.
Impression:
ICB with midline shift.
On POD2, he was extubated. Pre-extubation GCS E4 VT M6.
Monday, June 22, 2009
Right MCA territory Infarction with mass effect
Case: Refered from tanjung karang on 18/6/2009. 39 years old Indian gentleman, with no known medical illness developed sudden onset of left sided body wekness. He also had vomited few times whereby the vomitus was coffee ground.
Not on any medication. Been unwell since yesterday. Having nausea and persistent vomiting since yesterday. He was unable to tolerate much orally. Today had persistent vomiting too. At about 9 pm, had developed sudden onset of left UL and LL weakness associated with inability to speak. Denies having any headache, No giddiness, No fever, No preceding chest pain or palpitations. Married, Non smoker, occasional alcohol consumption
Examination:
Alert, Obeying commands. Expressive dysphasia. Gag reflex absent. Right UL and LL: dense hemiplegia with hyperreflexia.
Plantar upgoing right side
CVS s1s2 DRNM
lungs clear
PA-soft, non tender
Pupils - equal 3 mms, reactive.
Pulse 92 /min
Respiration 17 /min
Systolic Blood Pressure 117 mmHg Diastolic Blood Pressure 88 mmHg
SPO2 99 %
Analysis / Assessment
:
ECG - sinus rythm, LVH by voltage criteria
Analysis / Assessment
:
ECG - sinus rythm, LVH by voltage criteria
CT scan on 18/6/2009
Findings: Large ill defined wedge shaped hypodensity noted in the right fronto-parietal region with effacement of adjacent sulci. No midline shift. Ventricles and CSF-spaces are normal. Visualised paranasal sinuses are clear.
Impression: Right MCA territory recent infarct.
He underwent OGDS on 18/6/2009.
Findings:
Findings:
Esophagitis LA grade B with gastric metaplasiaChronic atrophic gastritis with antral erosionsDuodenum normal
On the next day noted pupils were unequal. Patient opens eyes, obeys commands, localizing to pain but not verbalizing
Examination:
pupils unequal RT 4mm lt 2mm
pupils unequal RT 4mm lt 2mm
BP 150/78
PR 74
Repeat Ct scan on 20/6/2009
Plain CT-brain on 20/6/09. Comparison with CT-scan on 18/6/09. Findings: The previously seen right MCA territory infarct become more well defined with increasing oedema. Associated mass effect to right lateral ventricle with midline shift 13 mm to left side. Hypodensity of midbrain, most likely represent ischaemia. Hyperintensity in basal cisterns and Sylvian fissures, suggestive of subarachnoid haemorrhage which was not seen before. Basal cisterns and sulci are effaced. Left basal ganglia recent infarct as seen before and not increasing in size. Left lateral ventricle is dilated.
He underwent right FTP decompressive cranictomy and left frontal EVD for ICP monitoring
Post-op he underwent cerebral resuscitation. Pupils 3s /2+. ICP maintanied below 20mmHg.
Post-op CT on 21/6/2009
PLAIN CT BRAIN: 21.6.2009 Finding: *** comparison with CT brain dated 20.6.2009. The left lateral ventricle is less dilated with EVD in situ. Lesser degree of midline shift to the leftc with shift of 4mm. Rest of the findings remains similar.
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