Download 2.Present illness

神經外科標準病歷範本-Admission Note
一、
1.Chief compalin
Loss of consciousness this morning
2.Present illness
This 68 year-old female has the hypertension and type 2 diabetes mellitus with regular control
by medications for years. According to the statement of his husband, she had been well in recent
time until this early morning. Her husband called her after himself woke up form bed but found that
she was in unconscious condition with upward gaze and tonic-clonic motor activity. This status
subsided without recovery of consciousness about 10 minutes later. She was brought to our ER
immediately, At ER, her vital signs showed high blood pressure with BP : 215/113mmHg. Her GCS
was E1V1M4. Brain CT was arranged due to suspicious of intracranial lesion. Brain CT revealed a
large hematoma ( 4cm) in right temporal lobe with rupture into ventricle, diffuse subarachnoid
hemorrhage and ventricular dilatation. Vascular lesion was suspected due to unspecific intracranial
hematoma and CT angiography was scheduled. A fusiform type aneurysm was noted over right
posterior communicating artery. Mannitol was prescribed at ER for increased intracranial pressure.
Antihypertensive agent also used. Endotracheal tube insertion was performed for air way protection.
Under the impression of right posterior communicating artery aneurysm rupture, she received
emergent craniectomy for clipping of aneurysm and evacuation of hematoma. Throughout the
whole medical course, there was no previous headache, no nausea, no vomiting.
3.Impressin
(1)Ruptured right posterior communicating artery aneurysm with intracranial hemorrhage,
subarachnoid hemorrhage and hemohydrocephalus.
(2)Acute respiratory failure
4.Plan
(1)Therapeutic plan:
A. Sign inform consents ( TAE or craniotomy )
B. Arrange emergent operation ( Craniectomy for removal of ICH and clipping of aneurysm +
External ventricular drainage )
C. Control blood pressure
D. IV form Nimodipine for prevention of vasospasm.
E. Critical care in NICU after operation.
(2)Education plan
Informed the high risk of rebleeding during operation which may cause mortality.
Other risk: severe brain swelling, hydrocephalus, seizure, vasospasm, electrolyte imbalance,
infection etc
二、
1.Chief Complain
Progressive left visual impairment for one year
2.Present Illness
A 52 years-old female patient has no previous systemic disease. According to her statement,
she had intermittent headache over her left occipital region, with unspecific time and duration in
recent 4-5 years. Intermittent photophobia was found by herself since Nov 2009. She went to local
ophthalmology clinic ( 國光眼科 ) for help. Her visual acuity during that time was 1.0/0.7(od/os).
No significant abnormality was found by the studies. As symptom persisted, she went to other
clinics and National Cheng Kung University Hospital ( NCKUH ). Visual evoked potential was
arranged at neurology out patient department but still no specific lesion was found. She went back
to 國光眼科 again on Nov 2010 due to progress of visual function ( unable to read document ). Her
visual acuity was 1.0/0.1 (od/os). As highly suspicious of intracranial lesion in progression, she was
referred to Tainan Municipal Hospital. Brain imaging studies were arranged. Brain MRI revealed a
2.5x2.5x2.0cm well enhanced lesion over inner third of left sphenoid ridge. Brain tumor was
impressed. She was then went to visit several doctors for second opinion. Surgery was
recommended. She cam to our Neurosurgery out patient department on 24 Nov. 2010 and was
admitted this time for operation, Throughout the medical course, there were no nausea, no vomiting,
no dizziness, no limbs weakness, no seizure, no memory deterioration.
3.Impression
Left inner third sphenoid ridge tumor, suspect meningioma
4.Plans
(1)Therapeutic plan
A. Sign inform consent ( operation or radiosurgery )
B. Arrange operation tomorrow ( Craniotomy for removal of tumor )
C. Scalp shaving today.
D. Prophylactic antibiotics
E. Arrange brain CT for intra-operative navigation.
F. Transfer to NICU for post-operative care.
(2)Education plan
G. Inform the risk of surgery ( rebleeding, infection, brain swelling, seizure, neurological
deficit, recurrent etc. )
H. Post-operative observation in NICU for 1-2 days. Transfer to ward according to clinical
condition.
三、
1.Chief Complain
Both lower limbs numbness and pain after walking for 6 months
2.Present Illness
This 63 years-old man had past history of hypertension and DM diagnosed about 7 years ago
under regular medical control, and osteoporosis. He once had traffic accident with hip contusion to
the ground about 3 years ago. He is a worker in book factory and had to move heavy objects during
work.
He complained of low back pain with radiation to buttock and leg for one year. Both lower limbs
numbness and pa especially after long-walking was also noted since 6 months ago. The symptom
got improve when he was sitting or leaning forward. Standing and bending backwards would make
the symptom worse. The numbness level was below bilateral legs. The pain got worse in recent one
month that he could just walk about 100 meters and then had to take rest. There was no urine or
stool incontinence. He once went to LMD for help where medication for pain control was given but
in vain. Therefore he went to our out patient department for help. Physical examination showed
limited range of motion in the back and straight leg rising test ( SLRT ) was less than 45 degrees.
There are no vascular pulsatile abnormality over both legs. The lumbar X-film showed : lumber
spine stenosis ( including loss of the normal intervertebral disc heigh, spur formation and spinal
instability). The MRI showed : L4-5, L5-S1 spinal stenosis with dura sac compression and neural
foraman narrowing. Therefore he was admitted to the NS ward for further evaluation and
management.
3.Impression
(1)Sciatica, bilateral
(2)L4-5,L5-S1 spinal stenosis
4.Plan
(1)Diagnostic plan
Arrange and EMG
(2)Therapeutic plan
A、Bed rest and analgesic for pain control
B、Arrange lumbar decompression surgery ( laminctomy, laminotomy, foraminotomy),
posterior fixation with or without instrumentation, posterior-lateral bone fusion or interbody
fusion
5.Educational plan
(1)Back muscle rehabilitation
(2)Bed rest and avoid move heavy object.