tokens: 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 &apos;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&apos;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 &apos;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.