Other specified disorders of metabolism Other specified acquired deformity of head Tobacco use disorder Other convulsions
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROSURGERY
 
Allergies: 
Bactrim / Keppra / zonisamide
 
Attending: ___.
 
Chief Complaint:
Skull defect, eosinophilic granuloma
 
Major Surgical or Invasive Procedure:
Left craniotomy and cranioplasty

 
History of Present Illness:
Patient is a ___ year old gentleman who was found to have an 
eosinophilic granuloma requiring craniotomy and cranioplasty 
whose pre-operative course has been complicated by possible 
seziure activity, evalauted by neurology and transitioned from 
keppra to zonisamide. He presents electively for repair of his 
granuloma
 
Past Medical History:
Right arm ORIF
 
Social History:
___
Family History:
NC
 
Physical Exam:
T 98.3 BP 100/80 P ___ (supine) 130/80 100 (sitting) 100/80 100
(standing) R 16 KPS 90. Mental status is satisfactory in areas 
of
alertness, orientation, concentration memory and language. Optic
discs are sharp. On cranial nerve examination, eye movements are
full, pupils are equal and reactive. Full visual fields. No
facial weakness, no dysarthria. No tongue weakness. On motor
examination, there is no weakness. Coordination is normal. Fine
movements are satisfactory. Light touch and vibration is
perceived well throughout. Reflexes are normoactive and
symmetric. Gait and station are normal. On general examination,
the oropharynx is clear, the lungs are clear, the heart is
regular, the legs are without edema or tenderness. There is
irregular left temporal skull defect with tenderness to touch. 

 
Brief Hospital Course:
Patient presented electively ___ ___ for craniotomy and 
cranioplasty for eosinophilic granuloma.
 
Medications on Admission:
zonisamide
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Eosinophilic granuloma

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

 
Discharge Instructions:
Have a friend/family member check your incision daily for 
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, 
or excessive bending.
**You have dissolvable sutures you may wash your hair. 
Increase your intake of fluids and fiber, as narcotic pain 
medicine can cause constipation. We generally recommend taking 
an over the counter stool softener, such as Docusate (Colace) 
while taking narcotic pain medication.
Unless directed by your doctor, do not take any 
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and 
Ibuprofen etc. 
If you were on a medication such as Coumadin (Warfarin), or 
Plavix (clopidogrel), or Aspirin, prior to your injury, you may 
safely resume after follow up
 Clearance to drive and return to work will be addressed at 
your post-operative office visit.
Make sure to continue to use your incentive spirometer while 
at home, unless you have been instructed not to. 

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE 
FOLLOWING

New onset of tremors or seizures.
Any confusion or change in mental status. 
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not 
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling, 
tenderness, or drainage.
Fever greater than or equal to 10.51° F.

 
Followup Instructions:
___

{'seizure activity': ['Other convulsions'], 'tenderness to touch': ['Other specified acquired deformity of head'], 'eosinophilic granuloma': ['Other specified disorders of metabolism']}