Closed fracture of first cervical vertebra Urinary tract infection site not specified Unspecified fall Ulcer of other part of foot Unspecified essential hypertension Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Gout unspecified Osteoarthrosis unspecified whether generalized or localized other specified sites
 
Name:  ___                    Unit 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:
CC: Arm weakness s/p fall
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
HPI: ___ fell in bathroom today and hit his neck, no LOC, did 
not hit his head, remembers the event clearly. He initially had 
total paralysis, and was seen initially at ___. 
Within a short while, he regained strength in his lower 
extremities, but had persistent weakness of LUE, 
proximal>distal, and RUE, though not as bad. He denies bowel or 
bladder symptoms.
 
Past Medical History:
HTN  
DM2  
History of hyperkalemia  
Gout  

 
Social History:
___
Family History:
___ has significant diabetes with 
complications 
 
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 2 to 1 bilaterally    EOMs:intact
Neck: some ttp posterior neck
Back:  no stepoffs or tenderness 
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    ___    G
R     4    4     4    4    4     5     5     5     5      5 
L     3    4-    4-   4-   4-    5     5     5     5      5

Sensation: Intact to light touch, mildly decreased in L ulnar
distrubtion.
Reflexes: B Pa 
Right     2  2
Left      2  2

Toes downgoing bilaterally
Rectal exam normal sphincter control

 
Pertinent Results:
CT:
Head: no infarct, no hemorrage, normal
NECK: Base of Odontoid fx 
___ 09:38PM   GLUCOSE-203* UREA N-26* CREAT-0.8 SODIUM-133 
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16
___ 09:38PM   WBC-13.4* RBC-3.74* HGB-10.6* HCT-30.4* 
MCV-81* MCH-28.3 MCHC-34.9 RDW-13.9
 
Brief Hospital Course:
Pt was admitted to neurosurgery service. His initial CT showed 
fracture at the base of the odontoid.  He underwent subsequent 
MRI showing cord contusion.  He was maintained in hard collar.  
He was seen by wound care nurse for left toe ulcer - recommended 
dry gauze dressing daily.  He was found to have UTI on UA and 
started on antibiotics. His arm strength improved while here. 
___ evaluated pt and suggested acute level rehab. Prior to D/C 
Pt has no neurological deficits, non-focal exam with c-collar in 
place for fx at the base of the odontoid. He will follow-up with 
Dr. ___ in 4 weeks.
 
Medications on Admission:
Medications prior to admission:
asa 81', insulin glargine, Pantoprazole 40',Lisinopril 5', 
metformin, hctz, glyburide 5'

 
Discharge Medications:
1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) 
Capsule, Sust. Release 24 hr PO HS (at bedtime).  
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 
hours) as needed.  
8. Insulin Glargine  Subcutaneous
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours) for 14 days: through ___.  
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.  
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed.  

 
Discharge Disposition:
Extended Care
 
Facility:
___ 
___
 
Discharge Diagnosis:
C1 fracture
diabetes
foot ulcer
UTI

 
Discharge Condition:
neurologically stable

 
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES 
 
·        Do not smoke
·        No pulling up, lifting> 10 lbs., excessive bending or  
twisting for two weeks.
·        Limit your use of stairs to ___ times per day
·        You are required to wear cervical collar at all times
·        You may shower briefly without the collar
·        Take pain medication as instructed; you may find it 
best if taken in the a.m. when you wake for morning stiffness 
and before bed for sleeping discomfort
·        Do not take any anti-inflammatory medications such as 
Motrin, Advil, aspirin, Ibuprofen etc.
·        Increase your intake of fluids and fiber as pain 
medicine (narcotics) can cause constipation
·        Clearance to drive and return to work will be addressed 
at your post-operative office visit
 
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE 
FOLLOWING:
 
·        Pain that is continually increasing or not relieved by 
pain medicine
·        Any weakness, numbness, tingling in your extremities 
·        Any change in your bowel or bladder habits
 
Followup Instructions:
___

{'Arm weakness': ['Closed fracture of first cervical vertebra'], 'Neck pain': ['Closed fracture of first cervical vertebra'], 'Fall': ['Unspecified fall'], 'Foot ulcer': ['Ulcer of other part of foot'], 'Hypertension': ['Unspecified essential hypertension'], 'Diabetes': ['Diabetes mellitus without mention of complication'], 'Gout': ['Gout'], 'Osteoarthrosis': ['Osteoarthrosis']}