Cerebral aneurysm nonruptured Atherosclerotic heart disease of native coronary artery without angina pectoris Nicotine dependence unspecified uncomplicated
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: NEUROSURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
groin pain
 
Major Surgical or Invasive Procedure:
___: Pipeline embolization of right ICA aneurysm 
 
History of Present Illness:
___ in ___ female well known to neurosurgery 
for ruptured aneurysm.  She initially presented with a terrible 
headache in ___ and underwent emergent coil embolization of a 
ruptured right posterior communicating artery aneurysm on 
___, at the time there was ___ II resolved.  She 
presented for a follow-up angiogram on ___, that showed 
that there was some residual at the neck, similar to the 
appearance at the end of the case.  She is felt to be a 
candidate for pipeline embolization.  We talked about the risks 
and benefits of that procedure and the ability to not need to 
follow the aneurysm once it was proven gone follow-up after
pipeline.  She is interested in proceeding.  
 
Past Medical History:
- ___ secondary to Right PCOMM aneurysm rupture (___)
 
Social History:
___
Family History:
no family hx of aneurysm
 
Physical Exam:
ON DISCHARGE:
=============
___ x 3. NAD.  PERRLA.  CN II-XII intact
LS clear
RRR
Abdomen soft, NTND
___ BUE and BLE, no drift
Groin site soft, without hematoma.  Peripheral pulses intact
 
Pertinent Results:
Please refer to ___ for pertinent imaging and lab results. 
 
Brief Hospital Course:
___ is a ___ year old female with history of ___ 
secondary to right pcomm aneurysm rupture in ___ s/p 
emergent coil embolization. Recent angiogram demonstrates 
residual filling of aneurysm and patient returns now for 
elective pipeline embolization of the right pcomm artery 
aneurysm. 

#Right PCOMM Aneurysm 
Patient presented to pre-op area, was assessed by anesthesia and 
taken to the OR on ___ for right pipeline embolization of 
PCOMM aneurysm. Patient tolerate the procedure well. Please 
refer to formal op report in OMR for further intra operative 
details. Patient was successfully extubated and transferred to 
the PACU for post op care. She remained stable overnight.  Due 
to her right groin pain US was done which was negative for 
pseudoaneurysm of hematoma.  Patient was discharged home on 
___.
 
Medications on Admission:
- clopidogrel 75 mg tablet, 1 tab PO daily 
- aspirin 325 mg tablet, 1 tab PO daily 
 
Discharge Medications:
1.  Acetaminophen 325-650 mg PO Q6H:PRN fever or pain  
2.  Docusate Sodium 100 mg PO BID  
3.  Senna 17.2 mg PO QHS  
4.  Aspirin 325 mg PO DAILY 
RX *aspirin 325 mg 1 (One) tablet(s) by mouth once a day Disp 
#*30 Tablet Refills:*2 
5.  Clopidogrel 75 mg PO DAILY 
RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp 
#*30 Tablet Refills:*2 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Residual Right PCOMM aneurysm 

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

 
Discharge Instructions:
Discharge Instructions
Dr. ___ 

Activity

- ___ may gradually return to your normal activities, but we 
recommend ___ 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.

- ___ 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.
- ___ make take a shower.

Medications

- Resume your normal medications and begin new medications as 
directed.

- ___ may be instructed by your doctor to take one ___ a day 
and/or Plavix. If so, do not take any other products that have 
aspirin in them. If ___ are unsure of what products contain 
Aspirin, as your pharmacist or call our office.

- ___ may use Acetaminophen (Tylenol) for minor discomfort if 
___ are not otherwise restricted from taking this medication.

- If ___ take Metformin (Glucophage) ___ may start it again 
three (3) days after your procedure.

Care of the Puncture Site

- ___ 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.

- ___ may use a band-aid if ___ wish.

What ___ ___ Experience:

- Mild tenderness and bruising at the puncture site (groin).

- Soreness in your arms from the intravenous lines.

- Mild to moderate headaches that last several days to a few 
weeks.

- Fatigue is very normal

- Constipation is common. Be sure to drink plenty of fluids and 
eat a high-fiber diet. If ___ are taking narcotics (prescription 
pain medications), try an over-the-counter stool softener.

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

- Extreme sleepiness and not being able to stay awake

- Severe headaches not relieved by pain relievers

- Seizures

- Any new problems with your vision or ability to speak

- Weakness or changes in sensation in your face, arms, or leg

 
Followup Instructions:
___

{'groin pain': ['Cerebral aneurysm'], 'terrible headache': ['Cerebral aneurysm'], 'ruptured aneurysm': ['Cerebral aneurysm']}