101407944 PUMC
3925529
441763
2345939
4/30/2005 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY NAME :
CAUGH , DI K
UNIT NUMBER :
569-82-26
ADMISSION DATE :
04/30/2005
DISCHARGE DATE :
5/14/05 05/14/2005
PRINCIPAL DIAGNOSIS :
Right parietal occipital temporal tumor .
PRINCIPAL PROCEDURE :
5/5/05 right parietal occipital craniotomy and debulking of tumor using stulz neuro navigation .
HISTORY OF PRESENT ILLNESS :
The patient is a pleasant 83-year-old retired psychiatrist who presents with a chief complaint of gait difficulty for the last five to six months .
The patient has a history of laryngeal cancer in 2000 and 2001 , CVA in 2001 to 2002 and hypertension , who has a six month history of progressive difficulty in ambulation .
The patient was in previously good health when he reports starting to notice problems ambulating about six months ago .
His partner also reports that he has been having more difficulty with ADLs .
He reported that he began with difficulty buttoning his shirt for many years since after a stroke but now reports that on occasion she would ask him why he was doing certain things and he could not give a concrete example .
The patient was having a hard time walking and reports that he has felt weaker .
He has had uncoordination of his feet and began having a cane four to five months ago with the increasing weakness .
This was especially bad when trying to arise .
The patient has seen his primary care physician who referred him to physical therapy for his gait weakness but his symptoms failed to improve .
He continued to progress until two weeks prior to admission when he was found in the bathtub , unsteady and fell trying to steady himself .
The patient could not be moved and had to have 911 called for help .
Since that time he had been ambulating with a walker and has had increasing difficulty with falls in the last two weeks .
The patient was again seen by his primary care physician and a CG scan revealed a mass in the right parietal lobe .
The patient was referred to the Neurology Service for further workup of the mass .
The patient denied blurry vision , headache , nausea , vomiting , paresthesias , pain in mental status , confusion or seizures .
The patient is status post radiation therapy and resection and reconstruction for his laryngeal cancer .
REVIEW OF SYSTEMS :
Positive weakness , otherwise negative .
PAST MEDICAL HISTORY :
Hypertension , CVA 2001 , 2002 diabetes , laryngeal cancer , right CEA , prostatectomy for BPH , total knee replacement , status post appendectomy .
MEDICATIONS PRIOR TO ADMISSION :
Plavix 75 mg every day , Lipitor 40 mg every day , HCTZ 50 mg , Monopril 10 mg every day , Viagra 100 mg prn .
ALLERGIES :
NKDA .
FAMILY HISTORY :
Father with CAD at 90 , diabetes , CVA , hypercholesterolemia .
SOCIAL HISTORY :
The patient has one to two pack x20 year history of smoking that was 30 years ago .
He reports occasional alcohol use and no illicits .
The patient is a retired psychiatrist who lives in Ph .
PHYSICAL EXAM :
Afebrile , vital signs stable but notable for a blood pressure of 164/80 .
Generally a well developed elderly man in no apparent distress sitting in bed .
HEENT ;
extraocular movements intact .
Pupils equally round and reactive to light .
No nystagmus .
No retinal hemorrhages .
External ears normal .
Moist buccal mucosa , poor dentition , no erythema or exudates in the posterior pharynx .
Neck supple .
Prominent salivary glands bilaterally .
No other masses or thyromegaly noted .
No cervical , para-auricular or clavicular lymphadenopathy .
Chest :
Crackles in the right lung field .
No egophony .
Heart :
no palpable thrill or heave .
S1 , S2 .
3/6 systolic ejection murmur heard best at the apex .
Pulses 2+ carotids bilaterally , 2+ radial pulses , 2+ DP pulses bilaterally .
The abdomen was soft , nontender , nondistended , positive bowel sounds .
No hepato or splenomegaly .
Right lower quadrant scar and inferior midline scar that are well healed .
Back :
No CVA tenderness .
Skin :
No petechiae .
Cranial nerves II through XII grossly intact with a slight deviation of the uvula and tongue to the right .
There is increased tone in his right upper extremity with a slight left pronator drift .
On the right side his strength was 5 out 5 .
On the left side it is 4 out of 5 in the lower extremities .
The patient has an intention tremor with the left hand .
His reflexes were symmetric with upgoing toes .
There was a plantar grasp present on the left hand .
Graphesthesia was poor in both hands .
His gait was unsteady and he was unable to stand on his own .
Mental status :
he was alert and oriented x3 .
RELEVANT LABORATORY DATA :
White blood cell count on admission 6.1 , INR on admission 1.0 , relevant imaging .
Echocardiogram June 2004 showed an EF of 77% .
Chest xray reveals no consolidation or signs of edema .
CT shows a right parietal hyperdense and heterogenously enhancing mass measuring 6.5 x 5 cm with the surrounding vasogenic edema in effacement of the right lateral ventricle .
The finding was most consistent with metastatic disease and less likely primary CNS neoplasm such as glioblastoma .
MRI showed a large heterogenous enhancing right parietal mass lesion with a possible ependymal spread .
The patient was admitted to the Neurologic Service for workup of his tumor .
The neuro-oncologist felt that because of the tremendous tumor burden that was likely causing his symptoms the patient will require open debulking as well as obtaining issue for a pathologic diagnosis .
Thea patient was referred to Dr. Coma of the Eragnes Houseco Ardbay Memorial Hospital .
On May 5 , 2005 the patient was taken to the operating room for a right parietal occipital craniotomy and debulking of the tumor using stulz neuro navigation .
Please see the separately dictated operative report for further details of the procedure .
The patient was taken to the recovery room and then to the postoperative floor in stable condition .
Of note the patient was seen by cardiology for preoperative assessment .
The patient was also seen by physical and occupational therapy during his postoperative course and they recommended that he go to a rehabilitation facility for his recovery .
A postoperative MRI was obtained which revealed no remarkable findings but only post surgical changes .
Transcranial Dopplers were checked following surgery and the patient was started on Decadron 4 mg q6 to prevent swelling .
The patient was started on Fragmin for DVT prophylaxis and the patient was also started on Dilantin levels .
Of note on 5/9/05 the patient was seen by Urology due to an inability to void and a 16 French Coude catheter was placed .
The patient then was given voiding trials but eventually he needed to be straight cathed prn .
At the time of transfer , a 16 Coude catheter was in place and draining well .
The patient can have voiding trials at rehab and he is being maintained on Flomax .
The patient had a relatively unremarkable course and his neurologic status continued to improve following the operation .
At the time of discharge the patient was alert and oriented x3 and able to swallow pureed and thick diet without a problem .
On 5/11/05 repeat imaging revealed some edema and mass affect .
The patient was given an IV load of Decadron and restarted on IV Decadron which was eventually transferred to po Decadron .
The patient was also started on Mannitol .
His pathology came back as a large grade IV glioma .
The patient 's pain was initially controlled with IV pain medications but at the time of discharge to the rehab facility he was able to control his pain on po pain medications .
The patient did have a postoperative serum sodium in the 120s from the 130s three days postoperatively .
An endocrine consult was obtained to help manage his serum electrolytes .
The patient was started on three grams of sodium , 3x a day with fluid restriction .
Over the next several days his sodium levels were followed and by 5/12/05 his plasma sodium was back to 136 .
The patient was taken off fluid restriction .
On 5/14/05 Mannitol was tapered and then d / c'd.
At the time of transfer the patient was stable and needed only physical and occupational therapy .
The patient was oriented to person , place and time and opened eyes appropriately to speech when asked .
The patient is hard of hearing .
The patient had no complaints of pain .
DISCHARGE MEDICATIONS :
1. Lipitor 40 mg po every day .
2. Captopril 12.5 mg po tid .
3. Nexium 40 mg po every day .
4. Colace 100 mg po bid .
5. Ativan 0.5 mg po q4 hours prn for anxiety .
6. Allegra 60 mg po bid .
7. Dilantin 100 mg IV tid which can be changed to a po regimen in seven days .
8. Zinc 220 mg po every day .
9. Vitamin C 500 mg po bid .
10. Flomax 0.4 mg po every day .
11. Fragmin 2500 units subcut every day .
12. Levofloxacin 500 mg po q daily x10 days .
13. Dexamethasone 4 mg po q6 hours .
14. The steroid will be kept for now and tapered at a later date on follow up with Dr. Coma .
15. Regular insulin sliding scale with finger sticks qac and qhs .
16. Neutra-Phos 1.25 grams po as needed .
DISCHARGE INSTRUCTIONS :
The patient is instructed to not shower or bath until one week .
The staples were removed prior to discharge .
The patient is instructed not to drive .
The patient is asked to see a physician immediately or go to the nearest emergency room if any bleeding , wound infection , fever greater than 100.8 , intractable nausea and vomiting , headache , dizziness , numbness , pain or weakness occurs .
The patient instructed to call Dr. Coma 's office at 496-260-3297 to arrange for a follow up appointment in the Saintaelfoote Hospital at the first available time , one to two months after surgery .
The patient is also asked to call the Neuro / Oncology Service , the office of Dr. Britts at 430-884-2917 for a follow up appointment in three weeks .
The patient is asked to take a course of Dilantin for ten more days .
The patient is instructed not to undergo any heavy lifting until seen in clinic .
HOPETAMEMY K. THOREDUHEDREPS , M.D.
DICTATING FOR :
Electronically Signed ERIN KENGEKOTE , M.D.
05/14/2005 16:02
_____________________________ ERIN KENGEKOTE , M.D.
TR :
wy
DD :
05/14/2005
TD :
05/14/2005 1:10 P 441763
cc :
ERIN KENGEKOTE , M.D.