Cerebral aneurysm nonruptured Body mass index [BMI] 40.0-44.9 adult Essential (primary) hypertension Hyperlipidemia unspecified Obesity unspecified Unilateral primary osteoarthritis left knee Presence of right artificial knee joint Barrett's esophagus without dysplasia Long term (current) use of antithrombotics/antiplatelets
 
Name:  ___           Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROSURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Cerebral aneurysm
 
Major Surgical or Invasive Procedure:
___: Pipeline Embolization of Left ICA aneurysm

 
History of Present Illness:
___ with recanalized P-Comm aneurysm. She is s/p SAH w coiling 
___ Left P-comm. She presents today for pipeline embolization 
of left ICA aneurysm.
 
Past Medical History:
HTN
Hyperlipidemia
Depression
Arthritis
H Pylori
Colon polyp
Bilateral osteoarthritis of the knees
s/p right total knee replacement
Colon polyp
Gastritis
___ esophagus
 
Social History:
___
Family History:
No family history of neurologic diease or aneurysms.

 
Physical Exam:
ON DISCHARGE
============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious

Orientation: [x]Person [x]Place [x]Time

Follows commands: [x]Simple [x]Complex [ ]None

Pupils:  Right ___             Left ___

EOM: [x]Full [ ]Restricted

Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No

Pronator Drift [ ]Yes [x]No     Speech Fluent: [x]Yes [ ]No

Comprehension intact [x]Yes [ ]No

Motor:
TrapDeltoidBicepTricepGrip

IPQuadHamATEHLGast

Wound: CDI right groin, covered 
        

Angio Groin Site: [x]Soft, no hematoma  [x]Palpable pulses

 
Pertinent Results:
Please see OMR for pertinent imaging & lab results.
 
Brief Hospital Course:
On ___, Ms. ___ was admitted for pipeline embolization of L 
ICA aneurysm. Her operative course was uncomplicated; please see 
OMR note for full details. 

#ICA
Ms. ___ was transferred from the PACU to the ___. ___ her 
foley catheter was removed and she was encouraged to get out of 
bed as tolerated. She mobilized well and was discharge home.
 
Medications on Admission:
ASA 325, Plavix 75, HCTZ 25 qd, garlic, ___ 3 fatty 
acids. 
 
Discharge Medications:
1.  Acetaminophen 325-650 mg PO Q6H:PRN fever or pain  
2.  Aspirin 325 mg PO DAILY 
RX *aspirin 325 mg 1 (One) tablet(s) by mouth once a day Disp 
#*30 Tablet Refills:*1 
3.  Clopidogrel 75 mg PO DAILY 
RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp 
#*30 Tablet Refills:*1 
4.  Hydrochlorothiazide 25 mg PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Cerebral aneurysm

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

 
Discharge Instructions:
Angioplasty and Stent 

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.
It is very important to take the medication your doctor ___ 
prescribe for you to keep your blood thin and slippery. This 
will prevent clots from developing and sticking to the stent.
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.
The medication may make you bleed or bruise easily.
Fatigue is very normal.
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

Call ___ and go to the nearest Emergency Room if you experience 
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or 
coordination
Sudden severe headaches with no known reason

 
Followup Instructions:
___

{'Cerebral aneurysm': ['Cerebral aneurysm'], 'HTN': ['Essential (primary) hypertension'], 'Hyperlipidemia': ['Hyperlipidemia'], 'Depression': [], 'Arthritis': ['Unilateral primary osteoarthritis'], 'H Pylori': [], 'Colon polyp': [], 'Bilateral osteoarthritis of the knees': [], 's/p right total knee replacement': ['Presence of right artificial knee joint'], 'Gastritis': [], '___ esophagus': ["Barrett's esophagus without dysplasia"]}