Neurosurgeon's note

- 1 November 2024 - SMITH, John (and wife, Jane Smith) - Dr. Emily Carter - Follow-up - Cerebral aneurysm, I67.1 - Clipping of cerebral aneurysm, 15 October 2024 62 Male Subjective: - Reason(s) for consultation: Follow-up after cerebral aneurysm clipping. - Detailed history of the presenting complaint(s): Patient reports occasional mild headaches, no new neurological deficits. No visual disturbances or weakness. Headaches are infrequent and relieved with over-the-counter pain medication. - Past medical and surgical history: Cerebral aneurysm clipping (15/10/2024), hypertension. - Current medications: Aspirin 75mg daily, Amlodipine 5mg daily. - Social history: Non-smoker, occasional alcohol use, works as an accountant. - Allergies: No known allergies. Objective: - Vital signs: Blood Pressure 130/80 mmHg, Heart Rate 72 bpm, Temperature 37.0°C, Oxygen Saturation 98% on room air. - Physical examination findings: Neurological exam: Alert and oriented. Cranial nerves II-XII intact. No focal neurological deficits. Strength 5/5 in all extremities. Gait normal. - Investigation results: CT Angiogram of the head showed complete clipping of the aneurysm with no evidence of recurrence. Assessment & Plan: 1. Cerebral Aneurysm (Post-Clipping) - Assessment: Stable post-operative course. No evidence of aneurysm recurrence. Mild headaches likely related to post-operative recovery. - Investigations planned: None. - Surgical treatment planned: None. - Pre-operative preparation: N/A - Post-operative care plan: Continue current medication regimen. Follow-up appointment in 6 months. Educate patient on signs of recurrence (severe headache, vision changes, weakness). - Relevant referrals: None. Additional Notes: - Patient education and informed consent: Discussed the importance of regular follow-up and the signs and symptoms of aneurysm recurrence. Reviewed medication adherence. - Instructions for emergency care or signs to watch for post-operation: Instructed patient to seek immediate medical attention for sudden, severe headache, vision changes, or new neurological deficits. - Any specific patient or family concerns addressed during the consultation: Addressed patient's concerns about long-term prognosis and potential complications.