Subdural hemorrhage following injury without mention of open intracranial wound with no loss of consciousness Striking against or struck accidentally by other stationary object without subsequent fall Other left bundle branch block Unspecified essential hypertension Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
 
Name:  ___                  ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROSURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Intractable headache
 
Major Surgical or Invasive Procedure:
Bilateral burr holes for evacuation of SDH

 
History of Present Illness:
___ y/o male patient s/p hitting his head on the garage door on 
___. He came to the ED and was admitted to neurosurgery for 
chronic bilateral SDH. He had two stable head CTs and was 
discharged stable. Patient returned to the ED on ___ with 
intractable heachache. Head CT showed a new acute aspect in the 
chronic SDH and was admitted to neurosurgery. Patient denies any 
new trauma and being on anticoagulation. 
 
Past Medical History:
Left Bundle Branch Block
HTN
hyperlipidemia
BPH
 
Social History:
___
Family History:
NC
 
Physical Exam:
BP:156 /91         HR:69    R 14      O2Sats 98 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:  ___ ___ symmetric reactive       EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, Facial  sensation intact and symmetric.
VII- mild droop on left side, but strenghth intact
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift

Sensation: Intact to light touch, propioception,  and
vibration bilaterally. mild sensory loss over left lateral leg 
to
pain and temparature

Reflexes: B T Br Pa Ac
Right     ___ 2  2  
Left      ___ 2  2

Toes downgoing bilaterally

Coordination: mild dysmetria to finger-nose-finger on left side,
and sluggish rapid alternating movements on left,clumsy heel to
shin on left side

EXAM ON DISCHARGE:

Neurological exam non focal
small bilateral linear incisions on either side of his head 
closed with staples

 
Pertinent Results:
CT HEAD W/O CONTRAST ___ 
1. Mild increase in size of bilateral subdural collections, with 
an increase in the layering acute and subacute bleeds, 
suggesting rebleeding in the interval since the prior study. 
2. Fluid opacification of the right mastoid air cells, 
recommended clinical correlation. 

CT HEAD W/O CONTRAST ___
Stable appearance to acute-on-chronic bilateral subdural 
hemorrhage. 

CT HEAD W/O CONTRAST ___ 
1. New acute blood products in the right subdural collection. 
While the 
collection is stable in size, a portion of the fluid has been 
replaced by 
pneumocephalus. 
2. Decreased size of the left subdural collection, with 
unchanged amount of the more acute blood products in its 
dependent portion. 
3. Stable subdural hematoma along the tentorium and the falx. 

CT HEAD W/O CONTRAST ___ 
1. Stable bilateral subdural collections representing evolving 
hematomas.  
Stable pneumocephalus consistent with recent post-surgical 
changes. 
2. Stable subdural hemorrhage along the tentorium and falx. 
3. No evidence of new hemorrhage or mass effect. 
  
  

 
Brief Hospital Course:
Patient presented with intractable headaches and CT scan 
revealed bilateral chronic SDHs. Patient was admitted to 
neurosurgery for further workup. He denies any new trauma or 
anticoagulation. His repeat head CT on ___ was stable. On 
___ patient was pre-oped for the OR for bilateral burr holes 
for evacuation of SDH. Patient was placed on steroids 
pre-operatively for headache which was discontinued after 
evacuation. Post op head CT scan was stable. Physical therapy 
has celared the patient safe to go home, repeat head CT showed 
some acute residual blood. He had issues with voiding and after 
failure to void x2 foley was left in place. He will follow-up 
with Dr. ___ PCP tomorrow in which these issues will be 
addressed.  
 
Medications on Admission:
lipid lowering med ( cant recollect name)

 
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for headache.
Disp:*40 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day) as needed for seizure.
Disp:*60 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 
6 hours) as needed for pain/Temp>100/HA.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Bilateral SDH

 
Discharge Condition:
Stable

 
Discharge Instructions:
General Instructions

Have a friend/family member check your incision daily for 
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, 
or excessive bending.
You may wash your hair only after staples have been removed. 
If your wound closure uses dissolvable sutures, you must keep 
that area dry for 10 days. 
You may shower before this time using a shower cap to cover 
your head.
Increase your intake of fluids and fiber, as narcotic pain 
medicine can cause constipation. We generally recommend taking 
an over the counter stool softener, such as Docusate (Colace) 
while taking narcotic pain medication.
Unless directed by your doctor, do not take any 
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and 
Ibuprofen etc. 
If you have been prescribed Dilantin (Phenytoin) for 
anti-seizure medicine, take it as prescribed and follow up with 
laboratory blood drawing in one week.  This can be drawn at your 
PCPs office, but please have the results faxed to ___. 
If you have been discharged on Keppra (Levetiracetam), you will 
not require blood work monitoring.
Clearance to drive and return to work will be addressed at 
your post-operative office visit.
Make sure to continue to use your incentive spirometer while 
at home, unless you have been instructed not to. 

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE 
FOLLOWING

New onset of tremors or seizures.
Any confusion or change in mental status. 
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not 
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling, 
tenderness, or drainage.
Fever greater than or equal to 101° F.

 
Followup Instructions:
___

{'Intractable headache': ['Subdural hemorrhage following injury without mention of open intracranial wound'], 'Left Bundle Branch Block': ['Other left bundle branch block'], 'HTN': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'BPH': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)']}