Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Mental status changes, Thrombotic thrombocytopenic purpura
Clinical narrative: Date of Admission: 11/26/2023   Date of Discharge: 11/30/2023   Issues to be Addressed at Follow-up: Staples removal in 2 weeks w/ Neurosurgery  Follow up: w/ neuro-oncology  Pathology    Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/28/2023  2:50 PM SURGICAL PATHOLOGY In process BRAIN BIOPSY       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) BRAIN MASS   ? THROMBOTIC THROMBOCYTOPENIC PURPURA       TTP  presenting with altered MS  And deining features; ADAMST13 <1 RX;  Plasmapheresis , caplacizumab, Rituximab and steroids  No on steroid taper and Ruituximab theroy Last ADAMST 13 level 80    ? NONTRAUMATIC BRAIN COMPRESSION   ? COVID-19 DISEASE       11/26 cycle threshold - 42.2     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 60 year old male status post craniotomy for brain mass on 11/28 by Dr. Patient tolerated procedure well without complication. Patient was admitted in ICU for observation and was transfer to floor post op day 1 and was seen by PT. Patient was cleared by PT to go home with outpatient neuro PT for balance training. Hospital course was uneventful and patient d/c home.    Primary Procedures:  Procedure(s): CRANIOTOMY GLIOMA, COMPLEX   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Brain mass   Complications: none   Consults:  NEUROSURGERY - INITIAL INPATIENT CONSULTATION. NEUROSURGERY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     CRANIOTOMY MODULE   Urgency of craniotomy: Urgent (< or = 7 days)   Craniotomy indication: Primary Brain Tumor, intra-axial   Craniotomy Details: Supratentorial   Drains: No drain   Postoperative day when last drain was pulled:0   If craniotomy for brain mass, extent of resection: Gross Total Resection   FUNCTIONAL STATUS AT TIME OF ADMISSION: 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance   FUNCTIONAL STATUS AT TIME OF DISCHARGE: 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance   Craniotomy Hospital Events: No postop complications   Wound Status at time of discharge: No wound dehiscence Staples present at discharge   Residence Status at time of hospital admission:  Private residence  Residence Status at time of hospital discharge: Private residence   Hospital length of stay: Hospital Day(s): 4              Discharged within expected length of stay      Cosigned by: (M.D.) at 12/1/2023  2:03 AM  Note Details  Author (P.A.-C) File Time 12/1/2023  2:03 AM Author Type PHYSICIAN ASSISTANT (P.A.) Status Addendum Last Editor(P.A.-C) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 11/26/2023  Admission (Discharged) on 11/26/2023  Admission (Discharged) on 11/26/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  CRANIOTOMY GLIOMA, COMPL From 11/26/2023 to 11/27/2023 CRANIOTOMY GLIOMA, COMPL From 11/27/2023 to 11/29/2023  Hospital Problem List   BRAIN MASS  COVID-19 DISEASE  NONTRAUMATIC BRAIN COMPRESSION  THROMBOTIC THROMBOCYTOPENIC PURPURA Care Timeline  11/26   Admitted 2200 11/28   CRANIOTOMY GLIOMA, COMPLEX    Transferred to ICU 1835 11/29   Transferred out of ICU 1550 11/30   Discharged 1450  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/30/2023) Medication List at Discharge   acetaminophen 1,000 mg Oral EVERY 6 HOURS AS NEEDED  dexamethasone 2 mg Take 2 tablets by mouth 3 times a day for 2 days, THEN 2 tablets 2 times a day for 2 days, THEN 1 tablet 3 times a day for 2 days, THEN 1 tablet 2 times a day. And continue until directed by oncology.  docusate sodium 100 mg Oral 2 TIMES A DAY, (while taking oxycodone to keep stools soft)  levetiracetam 500 mg Oral 2 TIMES A DAY, (To prevent seizures)  oxycodone HCl 5 mg Take one half tablet orally every 6 hours AS NEEDED for moderate breakthrough pain (4-6), take 1 tablet orally every 6 hours AS NEEDED for severe breakthrough pain (7-10). Max 4 tabs per day.  sennosides 8.6 mg Take 2 tablets by mouth daily as needed for constipation. May increase up to 4 tablets by mouth 2 times a day as needed for severe constipation. Do not exceed 8 tablets in 24 hours