Medical Text: Admission Date:  [**2176-8-29**]              Discharge Date:   [**2176-9-6**]

Date of Birth:  [**2121-2-13**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Keflex

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Upper extremity weakness

Major Surgical or Invasive Procedure:
C5-C6 anterior cervical decompression and fusion, C1 tumor
removal

History of Present Illness:
55-year-old man with diabetes mellitus type 2, hypertension,
severe peripheral [**First Name3 (LF) 1106**] disease s/p R SFA stent angioplasty
and L SFA stent placement, congenital pulmonic valve stenosis,
CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p
ablation on warfarin, stage 3 diabetic nephropathy, intradural
tumor compressing his spinal cord at C1/C2, who was admitted on
[**2176-8-29**] to neurosurgery for anterior cervical decompression at
C5/6 fusion ([**8-29**]) and extradural tumor removal of C1 intradural
tumor ([**8-30**]).

The patient was post-operatively managed in the ICU with a
dexamethasone taper. He developed a small subdural hematoma
([**8-30**]) with no new neurologic symptom. Aspirin and heparin SC
were restarted. Clopidogrel, for L SFA stent, is scheduled to be
restarted on POD#5, [**2176-9-4**], and warfarin, for atrial
fibrillation, to be restarted on [**2176-9-9**].

Patient was extubated on [**9-1**], and is coming off a furosemide
drip for dCHF. [**Month/Day (4) **] is following the patient for a mottled
right foot and his recent [**Month/Day (4) 1106**] procedures.

Patient's other medical issues diabetes, HTN, CKD (Cr 1.1),
atrial fibrillation (HRs 70s-80s), CAD s/p stent and "chronic
hyponatremia" (Na 138) have been stable. Transfer is requested
for ongoing management of diastolic CHF.

On evaluation in the SICU before transfer, patient was sleeping
but arousable, complaining of old back pain and of constipation.
Vital signs were stable with O2 saturation 98% on 3L.


Past Medical History:
(1) Type 2 diabetes mellitus, requiring insulin, and the
complications from years of poor glycemic control:
-hypertension
-severe peripheral [**Month/Day (4) 1106**] disease
-peripheral neuropathy
-pressure, venous stasis, and neuropathic ulcers on his right
and left lower extremities
-stage 3 diabetic nephropathy
-renal insufficiency (baseline creatinine 1.5 to 1.7)
(2) Atrial fibrillation status post ablation [**2169**] and [**2174**], on
coumadin
(3) Congenital pulmonic valve stenosis status post two childhood
surgeries
-history of RV failure
-history of peripheral edema and anasarca
(4) Chronic hyponatremia
(5) Chronic low back pain status post car accident
(6) Spinal cord meningioma compressing his spinal cord at C1/C2
(7) COPD
(8) Coronary artery disease status post stenting [**2169**] (bare
metal stent by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] ([**Telephone/Fax (1) 8725**])) and repeat
stenting at [**Hospital1 18**] in [**2174**] (bare metal stent - see d/c summary
[**2175-2-7**])
(9) MI in [**2161**]

Social History:
The patient is married and has two adult sons who do not live at

home. He lives in [**Hospital1 1474**], MA. His wife works 60 hours a week,
and he is left at home for most of the day. He has been bedbound

for several years. A visiting nurse can only come once a week to

change the dressings on his lower extremity ulcers. His sons
struggle with alcoholism and heroin abuse. His younger son has
recently threatened suicide and homicide (against the patient's
wife), a source of much stress at home. He used to work as a
"bouncer" and in construction, and enjoyed riding his
motorcycle. The patient says he tries to keep a positive
attitude about his condition. He says he feels depressed, but
says he is not interested in therapy or medication for
depression. He has not seen his primary care physician [**Last Name (NamePattern4) **] 2
years because he will only travel in an ambulance but his PCP's
office is in touch with the patient and wife weekly.
-[**Name2 (NI) **] has a 2 pack per year smoking history for "several years"
-He drinks alcohol occasionally, and has never had a problem
with alcoholism
-He denies recreational or IV drug use



Family History:
Heart disease in unspecificed family members.

Physical Exam:
Physical exam on admission:
Gen: obese, deconditioned, pain with movement of extremities.
Extrem: B LE edema
Neuro:
Mental status: Awake and alert, cooperative with exam.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Motor: Patient with severe bilateral wasting of muscles of hand.
UE's: FI's:[**2-1**] WE 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [**1-4**] PF/DF
0/5 LLE: IP3/5 PF/DF 0/5


Pertinent Results:
[**2176-8-29**] 12:10PM   GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
[**2176-8-29**] 12:10PM   estGFR-Using this
[**2176-8-29**] 12:10PM   WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78*
MCH-24.9* MCHC-31.9 RDW-13.6
[**2176-8-29**] 12:10PM   PLT COUNT-206

IMAGING STUDIES:
# C-spine Xray [**8-29**]: Single lateral view of the cervical spine
obtained portably in the OR, labeled #1. C1 through the C4/5
disc space is visualized. The C5 vertebral body is faintly seen
-- bony structures lower than this are obscured by overlying
soft tissues. However, surgical markers are seen overlying the
anterior aspects of the C4-5 and C5-6 disc spaces, from an
anterior approach. Support tubing and temperature probles noted.


# C-spine CT [**2176-8-29**]:
1. New interval C5-C6 anterior fusion with intervertebral disc
spacer, no
immediate hardware complication. Post-surgical changes in the
soft tissue
with subcutaneous emphysema mostly in the right submandibular
region.
2. Mass at C1 level with associated cord compression consistent
with known
meningioma better described on recent MRI.
3. Soft tissue thickening at the right lung apex, not fully
characterized on the current CT. In comparison with CT neck from
[**2176-8-9**], it has increased in size. CT chest is
recommended to evaluate this further, if clinically warranted.

# Head CT [**2176-8-30**]:
1. New interval left frontal subdural hyperdense extra-axial
fluid collection with new interval subdural subfalcine
extra-axial hyperdense fluid collection, indicating subdural
hemorrhage, likely post-surgical but clinical correlation
recommended.
2. Pneumocephalus with distribution at the basilar cisterns,
mostly at the
left sylvian fissure, and bifrontally at the falx, likely
post-surgical, and additionally in the posterior fossa near the
site of the occipital craniotomy.
3. Post-surgical changes with left craniotomy at the occipital
bone and
laminectomy at C1 with subcutaneous emphysema and hyperdense
products, likely post-surgical.
4. Soft tissue hyperdensity at the posterior parietal, occipital
soft tissue region, could be small post-surgical hematoma.
.
# C-spine MRI [**2176-8-31**]: Status post resection of C1 extradural
tumor, likely meningioma with expectorated postoperative
changes. No large intraspinal hematoma seen. There remains some
persistent narrowing of the spinal canal at C1 level with
indentation on the posterior aspect of the spinal cord.
Continued followup recommended. Mild spinal cord atrophy could
be secondary to chronic myelomalacia.
.
# LE arterial Duplex [**2176-9-3**]: The peak systolic velocity
involving the native right common femoral artery is 104 cm/sec.
Velocities within the superficial femoral artery range from 85
to 234 cm/sec and that within the popliteal artery on the right,
is 25 cm/sec. On the left, peak systolic velocity within the
common femoral artery is 132 cm/sec, SFA, velocities range from
146-75 cm/sec and that within the popliteal artery is 85 cm/sec.

IMPRESSION: Findings as stated above which indicate widely
patent common
femoral, superficial femoral and popliteal arteries bilaterally.

.
PATHOLOGY:
# C1 tumor [**2176-8-30**]: Cervical medullary junction tumor:
Meningioma, psammomatous subtype (WHO Grade I). The tumor is
composed of meningothelial cells with numerous psammoma bodies
and collagen deposition with no typical features or mitotic
activity.



Brief Hospital Course:
55-year-old man with diabetes mellitus type 2, severe peripheral
[**Month/Day/Year 1106**] disease, CAD, diastolic CHF, atrial fibrillation,
presented for planned anterior cervical decompression at C5-6
and removal of C1 meningioma.

# Cervical myelopathy and meningioma: Patient underwent anterior
cervical decompression and C5/6 fusion on [**2176-8-29**] and removal of
C1 meningioma on [**2176-8-30**].
The patient was post-operatively managed in the ICU with a
dexamethasone taper. He developed a small subdural hematoma on
[**2176-8-30**] with no new neurologic symptom.  Per neurosurgery
recommendations, aspirin and heparin SC were restarted.
Clopidogrel, for recent left SFA stent, was restarted on POD#5,
[**2176-9-4**], and warfarin, for atrial fibrillation, is to be
restarted on [**2176-9-9**].  Of note, there was some concern that he
had developed LE weakness after his procedure, but after
re-evaluation with the neurosurgery team they felt that his
strength in his legs were his baseline and this was not a
change.  He continued to work with PT during his
hospitalization.

# Diastolic heart failure: The patient experienced an acute
exacerbation of his diastolic heart failure likely secondary to
significant fluid administration during surgery. He was placed
on a furosemide gtt in the SICU, which was transitioned to his
home dose of lasix on the floor.  At discharge he was slightly
under his admission weight of 115kg with O2 sats in the mid 90's
on room air.

# Peripheral [**Date Range **] disease. The patient recently underwent
bilateral SFA angioplasties and Left SFA stenting. In
preparation for his neurosurgery, the plavix was held
pre-procedure and was subsequently re-started on [**2176-9-4**].  He
underwent bilateral arterial ultrasound on [**2176-9-3**] which
demonstrated patent SFA and femoral arteries.

# Atrial fibrillation: The patient was not in atrial
fibrillation during his hospitalization. Given his need for
neurosurgery his coumadin was held. It is scheduled to be
restarted 10 days post-procedure ([**2176-9-9**]).  He was well
rate controlled at the time of discharge.

# DM II. The patient's insulin regimin was adjusted to 50 units
of insulin glargine nightly with humalog insulin sliding scale
and achieved good control of his blood sugars (FSBS 100-180).

# Pressure ulcers. The patient has a 2x2cm right heel full
thickness ulcer that was without odor or drainage. A right
dorsum small 1x1cm partial thickness ulcer. Wound care nursing
consult was obtained.  Pressure ulcer care was performed by
repositioning, skin cleansing and conditioner application, and
cover with ABD and kerlex.

# Coping. The pt expressed to some staff members that his mood
was poor and he was not coping well after his surgery.  He never
expressed suicidal ideations.  He further expressed that he was
extremely frustrated with his hospitalization and his inability
to walk and function independently.  Discussed the possibility
of talking to psychiatrists in the hospital, but he declined.
He felt that if these feeling persisted he would pursue further
psychiatric care.  A number for psychiatric services was
provided to him on discharge.

# Chronic pain syndrome: The patient was continued on his home
regimen of dilaudid 4mg PO Q3H:prn

# Chronic hyponatremia. The patient had a history of chronic
hyponatremia although his sodium remained between 130-140 during
this admission.


Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:
PRN as needed for constipation.
2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [**Hospital1 **]

(2 times a day): Hold for SBP<100.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or HR<60.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)

as needed for insomnia.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
8. Petrolatum     Ointment Sig: One (1) Appl Topical DAILY
(Daily): Please apply to leg wounds per wound care orders. thank

you!
.
9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation q6H: PRN as needed for shortness of
breath or wheezing.
11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain: Hold for RR<12 or sedation.
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN

as needed for itching.
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO BID: PRN as needed for constipation.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for diarrhea.
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times

a day) as needed for anxiety.
18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for dry mouth, sore
throat.
19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): Please apply to upper forehead and scalp for
seborrheic dermatitis (day 1 = [**2176-8-11**]). Also, please apply to
wound on left shin for overlying fungal infection(day 1 =
[**2176-8-15**]). Thank you!
.
20. Glycerin (Adult)     Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for headache: Hold for
somnolence.
22. Heparin drip
Heparin IV Sliding Scale (please see included scale):
Diagnosis: DVT/A-fib,
Patient Weight: 114.76 kg,
Initial Bolus: 0 units IVP,
Initial Infusion Rate: 1450 units/hr,
Target PTT: 60 - 100 seconds,
.
PTT <40: 4600 units Bolus then Increase infusion rate by 450
units/hr,
PTT 40 - 59: 2300 units Bolus then Increase infusion rate by 250

units/hr,
PTT 60 - 100*:,
PTT 101 - 120: Reduce infusion rate by 250 units/hr,
PTT >120: Hold 60 mins then Reduce infusion rate by 450
units/hr,
23. Insulin sliding scale
Glargine 46 units at bedtime;
Humalog sliding scale per included sliding scale.


Discharge Medications:
1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1)  Intramuscular
Q6H (every 6 hours) as needed for pruritis.
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4
hours).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-1**]  Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn.
13. simvistatin 10mg Qday
14. Petrolatum     Ointment Sig: One (1) Appl Topical DAILY
(Daily).
15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
16. Outpatient Lab Work
Chem 10 to monitor electrolytes and creatinine while taking
lasix
17. Turn and reposition off back prn and limit sit time to 1hour
at a time using pressure redistribution cushion. Cleanse skin
with wound cleanser or NS then pat dry nad apply aquafor to
gluteals and legs and feet daily
18. For heel and lateral foot ulcer apply thin layer of duoderm
wound gel, cover dorsum and lateral wound with adaptic and heel
with gauze followed by ABD pad, wrap iwth kerlix and change
daily
19. headrest to occiput  with frequent repositioning
20. please remove sutures from posterior neck on tuesday [**9-10**] [**2175**]
21. Please start warfarin on [**2176-9-9**] (post op day 10)
and monitor INR prn
22. check weight Qday


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]

Discharge Diagnosis:
Cervical myelopathy
C1 tumor with cervical myelopathy
Acute on chronic diastolic heart failure


Discharge Condition:
Stable, afebrile


Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2176-8-29**] for worsening upper
extremity weakness due to your spinal tumor. You underwent an
operation to remove the tumor. You also underwent an operation
to decrease the pressure on the spinal cord in your neck. You
will need to have the staples out from your surgical site on
[**2176-9-10**], which they will do at your rehab facility. An
appointment was made for you to follow up with Dr. [**Last Name (STitle) **] in 6
weeks.

Please return to the Emergency department for fever, chills,
difficulty breathing, worsening upper extremity weakness, or
worsening symptoms.

Followup Instructions:
1. [**Last Name (STitle) **] LAB
[**Hospital1 18**] [**Hospital Unit Name **], [**Location (un) **]
[**Location (un) **] surgery
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2176-9-26**] 3:15

2 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
LM [**Hospital Unit Name **], [**Location (un) **]
[**Location (un) **] surgery
Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2176-9-26**] 4:15

3. Dr. [**Last Name (STitle) 47032**] [**Name (STitle) **]
address: [**Doctor First Name **] [**Hospital Unit Name **] [**Location (un) 470**] [**Hospital Unit Name **]
phone:  [**Telephone/Fax (1) **]
appointment: [**2176-10-8**]  1:15PM

4. Psychiatry Clinic
[**Hospital1 18**] Psychiatry Clinic
Please call the bottom number to schedule an appointment if your
mood is sad or you are not taking pleasure in life:
[**Telephone/Fax (1) **]




ICD9 Codes: 2761, 5119, 4280, 3572, 496, 412