Other nervous system complications Other specified surgical operations and procedures causing abnormal patient reaction or later complication without mention of misadventure at time of operation Unspecified essential hypertension Esophageal reflux
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Headaches
 
Major Surgical or Invasive Procedure:
1. Revision L4-5 and  L5-S1 laminectomy with medial facetectomy 
and foraminotomy at L4-5 and L5-S1.
2. Attempt at dural repair although a dural leak was not 
identified.

 
History of Present Illness:
This is a gentleman with positional headaches which persisted.  
He underwent lumbar microdiscectomy on ___ ___ 
___.  He was admitted to the hospital for the severity of 
these headaches. Lying flat, he had no headaches. A MRI was 
obtained which showed fluid both behind S1-S2 and in the canal 
as well as tracking to the subcutaneous tissue. Given his recent 
history of surgery as well as postural headaches, mild 
photophobia and nausea and vomiting
 
Past Medical History:
Hypertension
 
Social History:
___
Family History:
non contributory
 
Physical Exam:
On physical exam, he is approximately 6 feet 2 inches, weighing 
257 pounds with a blood pressure of 134/89 and pulse of 70.  He 
is a well-nourished male whose affect is appropriate and 
judgment appears to be intact.  He has a mildly antalgic gait 
favoring the left.  He is able to toe walk without difficulty; 
however, heel walking on the left is difficult, he is unable to 
keep his foot
dorsiflexed.  Alignment of his spine without any obvious 
scoliotic or kyphotic curvatures.  Skin is intact without any 
lesions, ecchymosis, or erythema.  He is nontender along his 
lumbar spine.  Lower extremity strength is ___ throughout with 
the exception of the left anterior tibialis which is 
approximately ___ in his left ___ which is approximately ___.  
He is sensory intact to light touch throughout.  Distal pulses 
are intact.  He has a mildly positive straight leg raising exam 
on the left in the supine position.  Negative clonus.  Reflexes 
were symmetrical bilaterally.  Calves are soft and nontender.

 
Pertinent Results:
___ 10:00AM BLOOD WBC-6.7 RBC-4.37* Hgb-13.4* Hct-36.3* 
MCV-83 MCH-30.8 MCHC-37.0* RDW-13.1 Plt ___
___ 07:40AM BLOOD WBC-7.3 RBC-4.57* Hgb-14.0 Hct-38.8* 
MCV-85 MCH-30.6 MCHC-36.1* RDW-13.1 Plt ___
___ 06:35AM BLOOD WBC-10.9 RBC-4.29* Hgb-13.2* Hct-36.2* 
MCV-84 MCH-30.7 MCHC-36.4* RDW-12.7 Plt ___

MRI L spine ___
IMPRESSION: Status post laminectomy at L5-S1 level on the left 
side with 
linear fluid collection extending from laminectomy site and from 
the right 
side of the thecal sac posteriorly to the subcutaneous fat where 
a small fluid collection is seen with ___ as described 
above. This could represent a CSF leak or postoperative seroma. 
Additionally, partially visualized in the sacral canal is a 
CSF-intensity collection which appears to be not contiguous with 
the thecal sac on the visualized images and could represent a 
CSF leak within the spinal canal. However, to exclude 
intraspinal arachnoid cyst or unusual extension of the thecal 
sac, correlation with patient's preoperative MRI would be 
helpful. Mild degenerative changes. 

 
Brief Hospital Course:
Mr. ___ was admitted to ___ for severe headaches, nausea & 
vomiting consistant with a dural leak.  He reciently underwent 
L4-5 microdiscectomy for a herniated disc on ___.  He 
tolerated that procedure well.  After MRI of his lumbar spine 
that showed fluid in the sacral region, the risks and benifits 
of exploratory surgery for a dural leak were discussed.  Mr. 
___ was concented and brought to the OR for his repair.  He 
tolerated the procedure well.  He was then brought to the PACU 
and then the general floor.  Mr. ___ was kept on bedrest for 
three days time.  The head of his bed was elevated slowly over 
the duration of a day.  He experienced no residual headaches, 
nausea or vomiting.  He was discharge to home. 
 
Medications on Admission:
None
 
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed.
Disp:*90 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
1. Cerebrospinal fluid (CSF) leak, L5-S1.
2. Status post L5 hemilaminectomy and diskectomy.

 
Discharge Condition:
stable to home

 
Discharge Instructions:
Please keep incision clean and dry.  You may shower in 48 hours, 
but please do not soak the incision.  Change the dressing daily 
with clean dry gauze.  If you notice drainage or redness around 
the incision, or if you have a fever greater than 100.5, please 
call the office at ___.  Please resume all home 
mediciation as prescribed by your primary care physician. You 
have been given additional medication to control pain.  Please 
allow 72 hours for refills of this medication.  Please plan 
accordingly.  You can either have this prescription mailed to 
your home or you may pick this up at the clinic located on 
___ 2.  We are not allowed to call in prescriptions for 
narcotics to the pharmacy.   If you have questions concerning 
activity, please refer to the activity sheet.
 
Followup Instructions:
___

{'headaches': ['Other nervous system complications'], 'nausea': ['Other nervous system complications'], 'vomiting': ['Other nervous system complications'], 'photophobia': ['Other nervous system complications'], 'mild antalgic gait': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'difficulty heel walking': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'unable to keep foot dorsiflexed': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'mildly positive straight leg raising exam': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'CSF leak': [' or later complication', 'without mention of misadventure at time of operation'], 'fluid collection': [' or later complication', 'without mention of misadventure at time of operation'], 'herniated disc': [' or later complication', 'without mention of misadventure at time of operation'], 'hypertension': ['Unspecified essential hypertension'], 'esophageal reflux': ['Esophageal reflux']}