Disruption of external operation (surgical) wound Multiple myeloma without mention of having achieved remission Aphasia Unspecified essential hypertension Other and unspecified hyperlipidemia Other postprocedural status Arthrodesis status Surgical operation with implant of artificial internal device causing abnormal patient reaction or later complication,without mention of misadventure at time of operation Knee joint replacement
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PLASTIC
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Spine wound
 
Major Surgical or Invasive Procedure:
1. Debridement of skin down to bone of thoracolumbar wound (25 x
10cm).
2. Paraspinous flap x2 coverage of the previous spinal fusion
    hardware.
3. Complex closure of back incision (25 cm).
4. Removal of spinous processes of T9, T10, and L2, L3.

 
History of Present Illness:
___ s/p T11-L2 fusion and laminectomy and T12 corpectomy for T12 
lumbar stenosis ___ multiple myeloma mets, performed by Dr. 
___ on ___. The patient will undergo radiation treatment 
in the future, but no prior XRT. Patient was discharged to rehab 
following discharge on ___. She returned on ___ to the ED with 
lumbar wound dehiscence in addition to increasing confusion 
beyond baseline. She was discharged with wet to dry dressing 
changes to area and comes in today for closure of her lumber 
wound.

 
Past Medical History:
SAH, s/p b/l Aneurysm clipping.  With frontal craniotomy.
Residual aphasia.
HTN
Hyperlipidemia
Right knee replacement
VP shunt
Multiple myeloma  
T12 extracavitary corpectomy for removal of tumor ___
 
Social History:
___
Family History:
Multiple family members, particularly cousins with brain 
aneurysms requiring clipping, some of who had strokes.
No history of cancer in the family. 
 
Physical Exam:
AM vital signs: T97.9, P71, BP116/60, RR18, 100RA
Gen: Sitting in bed, eating, NAD.  Alert, expressive aphasia per 
baseline
Lungs: Breathing nonlabored
CV: RRR
ABD: Soft, NT/ND
Extrem: WWP x4
Back: Dressing changed on midline of back this AM.  Incision 
intact with mild weeping, no gross bleeding or exudate.  JP 
drains in place (1 midline, 1 Right Lateral, both with serrosang 
outtput).  
 
Brief Hospital Course:
BRIEF HOSPITAL COURSE
- ___ was admitted on ___ for spine wound washout and closure. 
 The patient tolerated the procedure well without complications.

Neuro: Post-operatively, the patient received PO Oxycodone with 
good effect and adequate pain control. 

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 quickly advanced when 
appropriate, which was tolerated well.  She continued her normal 
bowel regimen of Polyethylene Glycol 17g per day.  Foley 
remained in place per usual.

ID: As the wound did not appear infected, she recieved no post 
op antibiotics. The patient's temperature was closely watched 
for signs of infection. 

Prophylaxis: The patient received subcutaneous heparin during 
this stay as per her usual.

At the time of discharge on POD#2, the patient was doing well, 
afebrile with stable vital signs, tolerating a regular diet, had 
her usual menal status, and pain was well controlled. 

 
Medications on Admission:
1. Allopurinol ___ mg PO DAILY 
2. Atenolol 25 mg PO DAILY 
3. Atorvastatin 20 mg PO DAILY 
4. Calcium Carbonate 1250 mg PO DAILY 
5. Dexamethasone 4 mg PO DAILY 
6. Cardizem CD *NF* 240 mg Oral Daily 
7. Dipyridamole-Aspirin 1 CAP PO BID 
8. Famotidine 20 mg PO DAILY 
9. Furosemide 20 mg PO DAILY 
10. Heparin 5000 UNIT SC TID 
11. Losartan Potassium 50 mg PO DAILY 
12. Polyethylene Glycol 17 g PO DAILY 
13. Senna 1 TAB PO BID 
14. TraZODone 25 mg PO HS 
15. Acetaminophen 650 mg PO Q6H:PRN fever/pain 
16. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain 

 
Discharge Medications:
No change to discharge medications

1. Acetaminophen 650 mg PO Q6H:PRN fever/pain 
2. Allopurinol ___ mg PO DAILY 
3. Atenolol 25 mg PO DAILY 
4. Atorvastatin 20 mg PO DAILY 
5. Calcium Carbonate 1250 mg PO DAILY 
6. Cardizem CD *NF* 240 mg ORAL DAILY 
7. Dexamethasone 4 mg PO DAILY 
8. Dipyridamole-Aspirin 1 CAP PO BID 
9. Famotidine 20 mg PO DAILY 
10. Furosemide 20 mg PO DAILY 
11. Heparin 5000 UNIT SC TID 
12. Losartan Potassium 50 mg PO DAILY 
13. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain 
14. Polyethylene Glycol 17 g PO DAILY 
15. Senna 1 TAB PO BID 
16. TraZODone 25 mg PO HS 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Spine wound, takent to the OR for washout and closure

 
Discharge Condition:
Overall Condition - Good
Mental status - Per usual, alert with expressive aphasia
Ambulation - Non ambulatory per usual

 
Discharge Instructions:
POST OPERATIVE GENERAL DISCHARGE INSTRUCTIONS:  
Personal Care:   
1. Clean around the drain site(s), where the tubing exits the 
skin, with soap and water.  
2. Strip drain tubing, empty bulb(s), and record output(s) ___ 
times per day.  
3. A written record of the daily output from each drain should 
be brought to every follow-up appointment. Your drains will be 
removed as soon as possible when the daily output tapers off to 
an acceptable amount.  

Activity:  
1. You may resume your regular diet.  
2. Activity as tolerated.  OK to roll patient, but be careful 
not to tug on her incision (ie, roll from shoulder and hip, DO 
NOT pull from her back or side).

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.  
3. Take prescription pain medications for pain not relieved by 
tylenol.  
4. Take Colace, 100 mg by mouth 2 times per day, while taking 
the prescription pain medication. You may use a different stool 
softener if you wish.

Call the office IMMEDIATELY if you have any of the following:  
1. Signs of infection: fever with chills, increased redness, 
swelling, 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.  
.  
DRAIN DISCHARGE INSTRUCTIONS  
You are being discharged with drains in place. Drain care is a 
clean procedure. Wash your hands thoroughly with soap and warm 
water before performing drain care. Perform drainage care twice 
a day. Try to empty the drain at the same time each day. Pull 
the stopper out of the drainage bottle and empty the drainage 
fluid into the measuring cup. Record the amount of drainage 
fluid on the record sheet. Reestablish drain suction.  
 
Followup Instructions:
___

{'Spine wound': ['Disruption of external operation (surgical) wound'], 'Expressive aphasia': ['Aphasia'], 'Multiple myeloma': ['Multiple myeloma', 'without mention of having achieved remission'], 'Hypertension': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Postprocedural status': ['Other postprocedural status'], 'Arthrodesis status': ['Arthrodesis status'], 'Abnormal patient reaction': ['Surgical operation with implant of artificial internal device causing abnormal patient reaction', 'or later complication', 'without mention of misadventure at time of operation'], 'Knee joint replacement': ['Knee joint replacement']}