Benign neoplasm of cerebral meninges Cerebral embolism with cerebral infarction Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Atrial fibrillation Unspecified essential hypertension Other and unspecified hyperlipidemia Old myocardial infarction History of fall Long-term (current) use of anticoagulants Personal history of malignant neoplasm of prostate
 
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:
Gait instability, multiple falls
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Mr ___ is a pleasant right handed ___ year old male with Afib, 
on coumadin, who is quite independent, living with his wife and 
was in a good state of health until mid last year. At that time 
his wife reports that he began having periods of disorganized 
speech and gait instability. He did not have a fall until 3 
months ago when he broke several ribs on his coffee table. He 
did not have any head trauma and was not scanned at an OSH. His 
garbled speech and unsteadiness have waxed and waned over the 
past 6 months and his wife reports that they are much improved 
when he takes his diuretics. Over this period he has lost ~20 
lbs. 
Last night he was sorting papers at the dining room table when 
he fell from standing because of the dizziness. He reports no 
LOC, no head trauma and was able to stand back up and continue 
his work. His wife placed him on the couch, but he got back up 
and fell in the bathroom - again he denies any LOC or head 
trauma, blaming his instability and ___ weakness. He had no 
tongue biting or loss of bowel/bladder continence. He went to 
bed last night, but the morning of presentation his wife was 
concerned about his falls and brought him to the ED. He does 
have a diagnosis of DM II from just over a month ago and has 
started oral hypoglycemics for which he reports having low ___ at 
home. He was seen by an outside neurologist the week prior who 
had ordered a CT head to be completed the following week. In the 
ED his head was scanned which revealed no bleed but a 3x3 L 
frontal lobe extra-axial mass with compressive effect but
no midline shift. Neurosurgery was contacted for evaluation of 
the mass and its possible role in the patient's recent symptoms. 

 
Past Medical History:
DM II, HTN, HL, MI (in past), AF on coumadin, prostate CA 
treated non-operatively

 
Social History:
___
Family History:
Non-contributory 
 
Physical Exam:
At Admission: 

Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4->3    EOMs intact b/l
Lungs: CTA bilaterally.
Cardiac: irreg irreg with ___ holosystolic murmur.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech is fluent, good comprehension. Difficulty with
repitition. 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, VII: Facial strength and sensation intact and symmetric.
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. Mild R sided
pronator drift. Gait unsteady, rhomberg test with unsteadiness.

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     ___ 1  1
Left      ___ 1  1

Toes downgoing bilaterally

Coordination: heel to shin intact, finger nose-finger slowed and
overshooting with R hand. Difficulty with rapid alternating
movements with R hand.

AT DISCHARGE: 
Afeb, VSS
Gen: NAD.
HEENT: Pupils: 3->2  EOMs intact b/l
Lungs: clear b/l
Cardiac: irreg irreg with ___ holosystolic murmur.
Abd: non-tender/non-distended
Extrem: no edema or erythema, warm well perfused.

Neuro:
Mental status: Awake and cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent, good comprehension.

Cranial Nerves:
II-XII tested and intact b/l

Motor: ___ strength b/l in UE and ___. No pronator drift. Gait 
steady, walking without assistance.

Sensation: Grossly intact b/l.

Reflexes: B T Br Pa Ac
Right     ___ 1  1
Left      ___ 1  1

Toes downgoing bilaterally
 
Pertinent Results:
___ 04:55AM BLOOD WBC-3.9* RBC-4.39* Hgb-13.5* Hct-40.7 
MCV-93 MCH-30.7 MCHC-33.1 RDW-15.5 Plt ___
___ 04:55AM BLOOD ___
___ 04:55AM BLOOD Glucose-115* UreaN-33* Creat-1.2 Na-142 
K-3.7 Cl-104 HCO3-33* AnGap-9
___ 06:25AM BLOOD Albumin-3.2*
___ 02:39PM BLOOD %HbA1c-7.7* eAG-174*
___ 06:25AM BLOOD Phenyto-4.6*

CT Head ___: 
IMPRESSION: 
1. Extra-axial lesion, containing foci of calcifications 
measuring up to 3 cm, which likely reflects an extra-axial mass 
such as a meningioma. An 
extra-axial hematoma, which would be subacute to chronic, is 
considered less likely. 
2. Loss of gray-white differentiation in the high left 
frontoparietal lobe, could reflect an acute infarct. 

MRI Head ___:
Acute to subacute bilateral infarctions with the largest focus 
in the left post-central gyrus. Appearance of the post-gyrus 
lesion is somewhat 
heterogeneous however and recommend attention on followup 
imaging for further evaluation to exclude the presence of an 
underlying mass. Two meningiomas in the left frontal region 
without significant mass effect.

ECHO ___:
Marked symmetric left ventricular hypertrophy with normal cavity 
size and regional/global systolic function. Mild aortic valve 
stenosis. Mild aortic regurgitation. Right ventricular free wall 
hypertrophy. Pulmonary artery systolic hypertension. Dilated 
ascending aorta. 
CLINICAL IMPLICATIONS: 
The patient has mild aortic stenosis. Based on ___ ACC/AHA 
Valvular Heart Disease Guidelines, a follow-up echocardiogram is 
suggested in ___ years. 
Based on ___ AHA endocarditis prophylaxis recommendations, the 
echo findings indicate prophylaxis is NOT recommended. Clinical 
decisions regarding the need for prophylaxis should be based on 
clinical and echocardiographic data. 

MRA Head/Neck ___:
Mild atherosclerotic disease of the basilar artery. There is no 
evidence of acute vascular abnormalities involving the 
intracranial arteries 

 

 
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgical service on ___ 
from the emergency room after having a series of falls on 
___. A CT of the head demonstrated a left frontal 
extra-axial mass as well as a more acute lesion in the parietal 
lobe on the left. Because of his recent falls, his coumadin was 
held and he was placed on an insulin sliding scale as there was 
some concern for hypoglycemia contributing to the unsteadiness. 

An MRI of this head was obtained which confirmed a meningioma 
overlying the L frontal lobe and a sub-acute infarct in the 
post-central gyrus on the left. While he did have distinct right 
sided weakness in the emergency room, on hospital day #2 this 
weakness had nearly completely resolved and his confusion was 
also better. A neurology consult was obtained given what 
appeared to be a sub-acute stroke on his MRI - they recommended 
restarting the pt's coumadin, holding the dilantin and checking 
an EEG, these were done while he was an inpatient. He also 
underwent a surface echo and an MRA of the brain and neck given 
the likely embolic nature of his strokes. 

Neurology will see him in 3 months with a repeat head MRI. 
___ also saw him for his diabetes managment 
and recommended changing his glipizide to 10 BID, and not 
starting insulin. His sugars were well controlled while in house 
and he did not have any episodes of hypoglycemia. From a 
neurologic standpoing, in-house he did quite well with resultion 
of his right sided weakness although his unsteadiness continued 
and he needed support while ambulating. 

___ recommended he go to a short term rehab until he was better 
able to compete transfers and ambulate with a walker. He will 
follow up with neurology and neurosurgery to discuss how to best 
manage his ischemic strokes and address the meningioma, 
respectively.
 
Medications on Admission:
Coumadin 2.5', prandin 0.5''', glipizide 5'', isosorbide 
dinitrate 10'', lisinopril 20, allopurinol ___, torsemide 5, 
metoprolol 50''', lipitor 10'

 
Discharge Medications:
1. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID 
(3 times a day).  
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 
(Daily).  
5. Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 
___.  
7. Torsemide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  

 
Discharge Disposition:
Extended Care
 
Facility:
-
 
Discharge Diagnosis:
Left frontal meningioma, left parietal sub-acute infarct, 
Diabetes

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
You should take your coumadin as prescribed.
You do not need anti-seizure medications any longer.
You should follow up with Dr. ___ Dr. ___ as 
listed below. You will need a follow up MRI to evaluate the 
small stroke you had on the left side of your brain. Take all 
medications as prescribed and follow up with Dr. ___ 
this week to check in.

General Instructions/Information
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, 
or excessive bending.
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 are being sent home on steroid medication, make sure 
you are taking a medication to protect your stomach (Prilosec, 
Protonix, or Pepcid), as these medications can cause stomach 
irritation.  Make sure to take your steroid medication with 
meals, or a glass of milk. 
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.
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.
Fever greater than or equal to 101° F.

 
Followup Instructions:
___

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