tokens: Admission Date : 2010-08-26 Discharge Date : 2010-09-02 Date of Birth : 1961-06-26 Sex : M Service : HISTORY OF PRESENT ILLNESS : Mr. Robert Mackey is a 49 year old gentleman with a 22 year history of diabetes mellitus . He has a history of peripheral neuropathy , kidney transplantation in 2003 secondary to diabetic nephropathy , as well as throat cancer in 2004 treated with local resection and radical neck dissection on the left as well as postoperative radiation . Mr. Mackey also had signs and symptoms consistent with cervical myelopathy ; a cervical MRI scan showed very impressive disc herniations at C5-C6 , less so at C4-C5 , with clear cut cord compression , particularly on the right side C5-C6 . Therefore , he was admitted for C4-C5 and C5-C6 anterior diskectomy with autologous bone graft and instrumented fusion . PHYSICAL EXAMINATION : Postoperative physical examination demonstrated that he was afebrile at 97 degrees ; blood pressure 145/80 ; pulse 60 ; respiratory rate 10 ; 100% on a non-rebreather . He was awake , alert , uncomfortable secondary to incisional tenderness at neck site as well as right iliac graft site . The wounds were clean , dry and intact , and flat . HOSPITAL COURSE : While in the PACU , Anesthesia was called because the patient became dyspneic and tachypneic and his SAO2 dropped to 89% . His respiratory rate was 30 on face mask . Interoperatively , he was positive two liters with a stable blood pressure and heart rate , although requiring some neo-synephrine interoperatively . He responded to intravenous Lasix with 3.2 liters of urine output as well as marked clinical improvement . The etiology for his congestive heart failure was determined likely to be diastolic dysfunction from increased heart rate as well as excess volume . No definite evidence for significant myocardial ischemia , although cardiac enzymes were sent and he ruled out for myocardial infarction . He was admitted to the Surgical Intensive Care Unit where his respiratory and cardiac status was monitored carefully . He was given Lasix to continue to diurese the excess volume . He was also put on Lopressor 150 mg twice a day . Also in the Intensive Care Unit , O2 saturation was closely monitored . The patient became agitated with both tent and Bi-PAP machine , although continued to saturate well . He was transferred to Medicine the morning of 2010-08-30 , for continued medical management post surgery . On the day of transfer , the patient was noted to be confused with waxing and waning sensorium ; thus , a delirium work-up was initiated looking for precipitants . 1. When his O2 saturation was monitored , his pulse oximetry remained in the 90s during his stay . 2. His non-essential medications that may have been contributing to his change in mental status were discontinued ; those included Temocillin , Nortriptyline , Haldol , Lorazepam , Venlafaxine , Bupropion , and Gabapentin . In addition , his cyclosporin levels were checked . 3. Hypo or hyperglycemia : Mahoney had been following with their appreciated recommendations on glucose control . Finger sticks were in the 150 s when acutely agitated , therefore , it was not determined that glucose levels were contributory . 4. Infectious causes were evaluated . He was febrile in the Intensive Care Unit to 101.0 F. ; yet , chest x-ray , blood cultures , urinalysis and urine cultures were all negative for sources . A lumbar puncture was considered , although not performed due to the fact that the cerebrospinal fluid was not breached during the procedure . 5. Mass effect was considered , although no focal deficits were ever noted on examination and due to the fluctuating sensorium , it was determined that there was no severe underlying structural abnormality . A head and neck CT scan , non-contrast , were ordered though to evaluate for such processes . No acute intracranial hemorrhages or midline shifts were noted , although a soft tissue mass was noted at the level of C2 . This was determined to be within the normal expected changes post surgery . 6. Trauma was also considered . The patient was found out of bed but no signs of head trauma , no loss of consciousness . Throughout his stay , Chem-10 was monitored . There were no electrolytes or mineral abnormalities that could explain his delirium . Liver function tests were checked , only total bilirubin was slightly elevated at 1.6 . TSH was within normal limits as was B12 and folate . RPR evaluating for possible neurologic syphilis was also checked . The assay was nonreactive . An EEG was also considered to rule out non-convulsive status epilepticus , although again this did not seem to be a likely cause . On the evening of the 22nd , the patient became acutely agitated , threatening to leave , and also threatening to harm those nurses and physicians that were attempting to prevent him from leaving . Security was notified who then arrived to the room and helped to place the patient in four-point restraints , for the safety of both the patient and the staff of the hospital . The restraints were weaned off overnight although he became acutely agitated and they were replaced early on 08-31 . Later in the morning on 08-31 , the patient was more oriented and alert , and asked to have the restraints removed . They were taken off two at a time . The patient continued to do well and did not require restraints after that event . Intramuscular as well as intravenous Haldol were ordered p.r.n. for emergency use should he become acutely agitated . haldol as well as the restraints were not required after the morning of the 23rd . Each progressive day, Mr. Donald delirium abated with return to baseline mental status early on 09-01 . The likely cause of the delirium was a combination of surgery and Intensive Care Unit stay in addition to poly-pharmacy . Other concerns during his stay was his kidney function , due to his renal transplant in 2003 . His immunosuppressive therapy was continued throughout his stay ; his creatinine remained approximately 2.3 to 2.4 ; he has a baseline renal insufficiency . With this in mind , when obtaining a CT scan it was determined that contrast would not be the best option . While the patient was in restraints , gentle hydration was initiated since p.o. intake was not adequate . As for his diabetes mellitus , the Mahoney Team provided updated recommendations each day , adjusting for the changing p.o. intake . The only other complaints from Mr. Mackey during his stay were : Soreness at his operative sites , for which he was given p.r.n. Tylenol once his delirium had resolved . In addition , he also complained of difficulty with swallowing , necessitating only soft and liquid diet . This was attributed to postoperative swelling and changes from his diskectomy performed 2010-08-27 . DISPOSITION : The patient was discharged on 09-02 . DISCHARGE INSTRUCTIONS : 1. Follow-up with Dr. Williams on Tuesday , 09-07 , at noon . 2. Follow-up with Dr. Michael , his psychiatrist , on Wednesday , 09-08 . 3. He was also discharged home with Visiting Nurse Association for Physical Therapy evaluation of home safety . DISCHARGE MEDICATIONS : 1. Venlafaxine XR 75 mg q. a.m. 2. Furosemide 20 mg q.o.d. 3. Metoprolol 100 mg twice a day . 4. Nitroglycerin sublingual 0.3 mg p.r.n. 5. Cyclosporin microemulsion . 6. Neoral 100 mg twice a day . 7. Zithropren 50 mg q. day . 8. Prednisone 10 mg q. day . 9. Minoxidil 10 mg twice a day . 10. Prilosec 20 mg q. day . 11. NPH 30 units q. a.m. , 5 to 6 units q. p.m. 12. Regular insulin 5 units q. a.m. and 3 to 5 units q. p.m. 13. Wellbutrin 100 mg q. day . 14. Zocor 60 mg q. day . 15. Nitroglycerin SR 2.5 mg twice a day . He was instructed to hold the following three medications that he took prior to admission : Nortriptyline 10 mg q. h.s. ; Flomax 0.4 mg q. h.s. ; Neurontin 600 mg three times a day . He was instructed not to restart these until seen by Dr. Ercek . DISCHARGE DIAGNOSES : 1. C4-C5 , C5-C6 , anterior microdiscectomy and fusion with right iliac bone graft . For completeness , the patient 's complete past medical history : 1. End-stage renal disease secondary to type 1 diabetes mellitus ; status post renal transplant in 2003 . 2. History of multiple urinary tract infections . 3. Pyelonephritis . 4. Creatinine 2.2 to 2.5 . 5. Right coronary artery stent in 2008 ; ejection fraction 60 to 65% . 6. Type 1 diabetes mellitus with triopathy , retinopathy , neuropathy , nephropathy . 7. Benign prostatic hypertrophy status post transurethral resection of the prostate ; self catheterization . 8. Hypertension . 9. Hypercholesterolemia . 10. Hepatitis B . 11. Throat cancer status post right neck dissection and XRT in 2004 . 12. Cerebral aneurysm . 13. Left prosthetic CMED CCU . ALLERGIES : Gentamicin , and ibuprofen . Kenneth Jeffrey , MD 89-808 Dictated By : Michael S Bonham , M.D. MEDQUIST36 D : 2010-09-02 18:23 T : 2010-09-07 16:04 JOB #: 36814 Signed electronically by : DR. Victoria Williams on : MON 2010-11-08 3:18 PM ( End of Report )