Cerebral aneurysm nonruptured Major depressive disorder single episode unspecified Anxiety disorder unspecified Family history of other specified conditions
 
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROSURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Aneurysm
 
Major Surgical or Invasive Procedure:
Pipeline embolization of Left ICA aneurysm

 
History of Present Illness:
She is a ___ nurse that works in the ___ in the dialysis
unit. She started noticing some tingling sensation on the right 
side of the face that did not disappear, and work up obtained an 
MRI/MRA; the report came back positive for aneurysm. +FH for 
aneurysm.  She presents today for Pipeline embolization of Left 
ICA aneurysm.
 
Past Medical History:
Anxiety
depression
 
Social History:
___
Family History:
her father is diagnosed with a 3 to 4 mm aneurysm that he has 
actually been followed by Dr. ___ here at ___, she had also 
two second-degree relatives with brain aneurysms.
 
Physical Exam:
on discharge:
___ x 3.  NAD.  PERRLA, 3-2mm.
CN II-XII intact.
LS clear
RRR
abdomen soft, NTND.
___ BUE and BLE.  No drift.
Groin site, clean, dry, intact without hematoma.
 
Pertinent Results:
Please see OMR for relevant imaging reports
 
Brief Hospital Course:
Pipeline embolization of her Left ICA aneurysm

On ___ she was admitted to the neurosurgical service and 
under general anesthesia had a successful Pipeline embolization 
of her Left ICA aneurysm. Her operative 
course was uncomplicated. For further procedure details, please 
see separately dictated operative report by Dr. ___. She was 
extubated, groin angiosealed and transferred to be recovered in 
the PACU and then transferred to the ___ when stable.  On POD 
#1 she remained stable.  She ambulated well independently and 
was discharged home.
 
Medications on Admission:
NuvaRing
lorazepam 0.5 ___ daily as needed
sertraline 25 mg daily
brilinta 90 bid 
aspirin 81 
 
Discharge Medications:
1.  Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 
no greater than 4 grams of Tylenol in 24 hours  
2.  Aspirin 81 mg PO DAILY 
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 (One) tablet(s) by 
mouth once a day Disp #*30 Tablet Refills:*1 
3.  Docusate Sodium 100 mg PO BID 
hold for loose stool.  Stop once done taking oxycodone  
4.  OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain 
decrease use as pain improves.  ___ request less than 
prescribed. 
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6) 
hours Disp #*20 Tablet Refills:*0 
5.  Senna 17.2 mg PO QHS 
hold for loose stools.  Stop once done taking oxycodone  
6.  TiCAGRELOR 90 mg PO BID 
RX *ticagrelor [Brilinta] 90 mg 1 (One) tablet(s) by mouth twice 
a day Disp #*60 Tablet Refills:*1 
7.  Sertraline 25 mg PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Aneurysm

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Activity
You may gradually return to your normal activities, but we 
recommend you take it easy for the next ___ hours to avoid 
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise 
should be avoided for ten (10) days. This is to prevent bleeding 
from your groin.
You make take leisurely walks and slowly increase your 
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5) 
days after your procedure.
You make take a shower.

Medications
Resume your normal medications and begin new medications as 
directed.
You may be instructed by your doctor to take one ___ a day 
and/or Plavix. If so, do not take any other products that have 
aspirin in them. If you are unsure of what products contain 
Aspirin, as your pharmacist or call our office.
You may use Acetaminophen (Tylenol) for minor discomfort if 
you are not otherwise restricted from taking this medication.
If you take Metformin (Glucophage) you may start it again 
three (3) days after your procedure.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and 
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.

What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few 
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and 
eat a high-fiber diet. If you are taking narcotics (prescription 
pain medications), try an over-the-counter stool softener.

When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture 
site. 
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg

 
Followup Instructions:
___

{'tingling sensation on the right side of the face': ['Cerebral aneurysm'], 'Anxiety': ['Anxiety disorder'], 'depression': ['Major depressive disorder']}