Encounter for planned post-operative wound closure Regional enteritis of unspecified site Personal history of irradiation presenting hazards to health Personal history of antineoplastic chemotherapy Depressive disorder not elsewhere classified Epilepsy unspecified without mention of intractable epilepsy Personal history of malignant neoplasm of brain
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PLASTIC
 
Allergies: 
Penicillins / Paxil / Wellbutrin
 
Attending: ___.
 
Chief Complaint:
exposed craniotomy hardware 
 
Major Surgical or Invasive Procedure:
Right scalp flap with split thickness skin graft and wound VAC 
placement

 
History of Present Illness:
___ year old female with multiple prior surgeries for right 
parietal anaplastic astrocytoma diagnosed in ___. She has also 
undergone chemo and radiation. She presented to ___ in 
___ with ___ month history of pruritus on the top of her head. 
She reports that she had her husband look at the top of her head 
and her found her metal hardware from her prior surgery was 
present. On ___ Dr. ___ metal hardware (removal of 
harware but not the bone flap). She presented today for a 
rotational flap and skin graft for proper coverage of wound. 
 
Past Medical History:
right parietal anaplastic astrocytoma,Craniotomy ___ by  
Dr. ___ in ___ irradiation to 6,120 
 
cGy ___ in ___,3 cycles of Temodar ended ___  
craniotomy on ___ by Dr. ___ at ___ ___ -  
___ wound revision and removal of the exposed craniotx 
hardware, Accutane for 2 weeks only ___ disease since 
___,  
tubal ligation,tonsillectomy, bronchitis, depression.  
seizures  

 
Social History:
___
Family History:
NC
 
Physical Exam:
Afebrile. vital signs stable. Right scalp incision clean, dry 
and intact with xeroform dressing in place. Right STSG site with 
bolstered xeroform dressing in place. No drainage or bleeding.
 
Pertinent Results:
None this admission.
 
Brief Hospital Course:
The patient was admitted to the plastic surgery service on 
___ and had a flap and skin graft to your scalp defect.  
The patient tolerated the procedure well. 
.
Neuro: Post-operatively, the patient received vicodin with good 
pain relief noted.
.
CV: The patient was stable from a cardiovascular standpoint; 
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint; 
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until 
tolerating oral intake. Her diet was advanced when appropriate, 
which was tolerated well. She was also started on a bowel 
regimen to encourage bowel movement. Intake and output were 
closely monitored. 
.
ID: Post-operatively, the patient was started on IV cefazolin, 
then switched to PO cefadroxil for discharge home. The patient's 
temperature was closely watched for signs of infection. 
.
Prophylaxis: The patient received subcutaneous heparin during 
this stay, and was encouraged to get up and ambulate as early as 
possible. 
.
At the time of discharge on POD#1, the patient was doing well, 
afebrile with stable vital signs, tolerating a regular diet, 
ambulating, voiding without assistance, and pain was well 
controlled. Her scalp graft site was clean and pink and she had 
xeroform dressing intact.  Her right thing graft donor site had 
original xeroform dressing in place to left open to air to dry 
out.

 
Medications on Admission:
___: azathioprine, Pentasa, topiramate, alprazolam, omeprazole, 
zolpidem, venlafaxine hcl er 30, popylthiouracil, promethazine, 
keflex 
 
Discharge Medications:
1. azathioprine 75 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 
8 hours) as needed for abdominal pain.  
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: 
One (1) Disk with Device Inhalation BID (2 times a day).  
4. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) 
Capsule, Extended Release PO QID (4 times a day).  
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
6. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times 
a day).  
7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) 
Capsule, Ext Release 24 hr PO DAILY (Daily).  
8. propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H 
(every 8 hours).  
9. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical 
BID (2 times a day).
Disp:*1 tube* Refills:*2*
10. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a 
day for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
11. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets 
PO every six (6) hours as needed for pain: Max 8/day. .
Disp:*40 Tablet(s)* Refills:*0*
12. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 
times a day) as needed for anxiety.  

 
Discharge Disposition:
Home With Service
 
Facility:
___ 
 
Discharge Diagnosis:
exposed craniotomy wound Status post hardware removal, split 
thickness skin graft application to scalp, donor site from leg

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

 
Discharge Instructions:
-The hemovac drain should always be collapsed so as to apply 
constant suction to the wound. Does not need to be emptied 
unless not collapsed and does not have suction.
-Your skin graft site on your scalp should be covered with a 
Xeroform dressing and you should apply bacitracin ointment with 
Qtips UNDER the xeroform dressing twice a day.  WARNING: do NOT 
change the xeroform that is sewn/sutured in place 
already...leave that in place.
-Please keep your skin graft site free of any pressure or 
extreme temperatures (cover with loose hat that does not sit on 
your graft site).
-You may shower 48 hours after surgery but do not let water run 
on your head/scalp area.  You may shower from the neck down 
only.
-your thigh 'donor site' should be left 'open to air' and left 
to dry out.  The old xeroform dressing will peel back/fall off 
on its own.  When you shower you must cover your thigh 'donor 
site' with Plastic wrap to keep it free of water while you 
shower.  You may remove plastic wrap when you are done and leave 
the donor site open to air again to dry out.
.
Diet/Activity: 
1. You may resume your regular diet. 
2. DO NOT bend over, avoid heavy lifting and do not engage in 
strenuous activity until instructed by Dr. ___. 
. 
Medications: 
1. Resume your regular medications unless instructed otherwise 
and take any new meds as ordered. 
2. You may take your prescribed pain medication for moderate to 
severe pain. You may switch to Tylenol or Extra Strength Tylenol 

for mild pain as directed on the packaging. Please note that 
Percocet and Vicodin have Tylenol as an active ingredient so do 
not take these meds with additional Tylenol. 
4. Take prescription pain medications for pain not relieved by 
tylenol. 
5. Take your antibiotic as prescribed. 
6. Take Colace, 100 mg by mouth 2 times per day, while taking 
the prescription pain medication. You may use a different 
over-the-counter stool softener if you wish. 
7. Do not drive or operate heavy machinery while taking any 
narcotic pain medication. You may have constipation when taking 
narcotic pain medications (oxycodone, percocet, vicodin, 
hydrocodone, dilaudid, etc.); you should continue drinking 
fluids, you may take stool softeners, and should eat foods that 
are high in fiber. 
8. do not take any medicines such as Motrin, Aspirin, Advil or 
Ibuprofen etc
. 
Call the office IMMEDIATELY if you have any of the following: 
1. Signs of infection: fever with chills, increased redness, 
welling, warmth or tenderness at the surgical site, or unusual 
drainage from the incision(s). 
2. A large amount of bleeding from the incision(s) or drain(s). 
3. Fever greater than 101.5 oF 
4. Severe pain NOT relieved by your medication. 
. 
Return to the ER if: 
* If you are vomiting and cannot keep in fluids or your 
medications. 
* If you have shaking chills, fever greater than 101.5 (F) 
degrees or 38 (C) degrees, increased redness, swelling or 
discharge from incision, chest pain, shortness of breath, or 
anything else that is troubling you. 
* Any serious change in your symptoms, or any new symptoms that 
concern you. 

 
Followup Instructions:
___

{'pruritus': ['Regional enteritis of unspecified site', 'Depressive disorder', 'Epilepsy unspecified without mention of intractable epilepsy'], 'exposed craniotomy hardware': ['Encounter for planned post-operative wound closure', 'Personal history of irradiation', 'Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain']}