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SOAP 1: john Edwards 36 male, business consultant

TERMS:

SUBJECTIVE

·         Head Trauma due to MVA.

·         Unconscious and gasping.

·         Blood running from nose and ears.

·         Several lacerations.

·         BP: 160/95.

·         Pulse 85.

·         Difficulty breathing.

OBJECTIVE

·         Tone on his right side reduced.

·         Reflexes increased.

·         Face was swollen.

·         Black eye.

·         Blood running from nose and ears.

·         Several lacerations.

·         BP: 160/95.

·         Pulse 85.

·         Difficulty breathing.

·         Dilated pupils

·         Sluggish response to light.

·         Epileptic attack caused by accident.

FINDINGS: SCANS

·         Le forte type 3 facial bones.

·         Ring enhancing lesion in frontal region (3rd frontal convolutions) 4cm in diameter.

·         Grey/white matter interface surrounded by marked oedema.

·         Central region appeared black.

·         Similar right parietal region lesions.

·          NO subdural or extradural haemorrhage.

·         Subarachnoid collection of blood in both frontal and occipital surface.

FINDINGS: SURGERY

·         Severe brain swelling caused by fungi cerebri.

·         Marked swelling after 10 hours

FINDINGS: PROBED FORNATAL LESION

·         High grade astrocytoma (grade 4: glioblastoma multiform)

·

ASSESSMENT

·         Skull X-ray.

·         CT scan.

·         Frozen section of lesion for diagnosis

·         4cm frontal lesion probed (core sent to pathologist)

·         Repeat scan of PCA infarct with haemorrhage in brain stem at level of pons/medulla.

PLAN

·         Endotracheal tube.

·         Emergency surgery

·         Stabilize facial bones.

·         Tx: mannitol for fungi infection.

·         Elected to remove frontal lobe on right side along with tumour.(less swelling)

·         Rehab: long period

·         Confined to wheelchair

OTHER

·         Ambulance waiting time.

·         Dependent on other for daily activities .

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SOAP 2 : Calvin February: high schooler, 17 yr.

TERMS: occiput: back of head.

Obtunded patient: similar to lethargy.

Gait: walking.

SUBJECTIVE

·         Unconscious during rugby match.

·         No weakness.

·         Fully awake and coherent but slightly agitated.

OBJECCTIVE

·         3cm laceration on occiput.

·         Slow on his feet

·         Unsteady gait.

·         Stumbles; unable to stand up.

·         Slurred speech.

·         Bruise anterior and superior to left ear.

·         Right arm and leg appear weak. (hour later)

·         Unequal pupils

FINDINGS: CAT SCAN

·         Fracture of left temporal lobe

·         Overlying large blood clot.

·         Reduced size to ipsilateral ventricles with dilation of contralateral side.

·         Evidence of transtentorial herniation: by ptosis and fixed dilated pupil on left side.

·         Raised intracranial pressure : slop pulse, high BP, papilloedema.

·         Now weakness on the right and left side of his body.

DIAGNOSIS

·         Extradural haemorrhage.

POST OPPERATIVLE

·         Weakness

·         Papilledoema

·         Ptosis

·         Papillary changes reverse

ASSESSMENT

·         CAT scan

·         Glasgow coma scale 6

PLAN

·         Suturing and tetanus booster.

·         Rushed to hospital. (paramedic)

·         Immediate decompression or death will ensure.

POST-OPP PLAN

·         Undergoes short rehab

·         No long term sequelae

OTHER

·         Consent given by uncle