Reference no: EM133906306

Question

Patient Name: Rodney Balbo DOB: 3/12/81 Anesthesia: General Pre-Surgical Diagnosis: Brain hematoma due to recent fall Post-Surgical Diagnosis: Brain hematoma due to recent fall Procedure Performed: Craniectomy for evacuation of hematoma in the subdural space of the cerebrum History: A 40- year-old male is being seen today for emergency surgery. Patient has history of hypertension, controlled with medication. Patient sustained a fall a week ago and was still experiencing a slight headache and drowsiness. After being referred to receive an MRI, the results indicated a brain hematoma as a result of the fall. Patient is being seen today for emergency surgery to remove the hematoma. The patient is prepped for surgery. The patient's hair was shaved in preparation for the procedure. Incision was made to the scalp and retracted. A drill was used to access the hematoma and the skull bone was removed. The bone was placed in sterile location. The hematoma was evacuated with suction and irrigated. The dura was sutured and closed. The incision was made to the abdominal region and the cranial bone graft was placed subcutaneously. Patient was sent to the post-operative area. Patient to follow up in office for post-surgical follow up in 3 days.