Sample Inpatient Chart 3 H&P and DS

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DISCHARGE SUMMARY

 

Final Diagnoses:

Active Hospital Problems

                Diagnosis              

•             (Principal) EPIDERMOID CYST, BRAIN        

 •            HTN (HYPERTENSION)     

•             HYPERLIPIDEMIA               

•             GERD (GASTROESOPHAGEAL REFLUX DISEASE)    

 

Resolved Hospital Problems

No resolved problems to display.

 

Discharge Disposition:

Home 

Medications, instructions, follow up information: See patient Discharge Instructions/AVS.

 

Hospital Course and Significant Findings:

Mr. ZZZ is a 54 Y man with a skull base tumor, likely epidermoid, bilaterally, who presented with L sided vestibular symptoms and L sided headaches. He underwent L suboccipital craniotomy for resection of the left sided component of the tumor at the cerebellopontine angle. Surgery was uncomplicated. Postoperatively, he was at his neurologic baseline. He was tolerating a regular diet, ambulating with minimal assistance, voiding spontaneously, and pain was managed with oral medications. His postoperative MRI showed complete decompression of cranial nerves 5-11 on the left side. He was discharged to home with supportive family.

 

Discharge exam:

Aox4

left lateral gaze, visual fields full to confrontation, face muscles and sensation symmetric, hearing intact bilaterally, palate elevates symmetrically, shrug full, tongue midline

Motor: full strength BUE and BLE. No pronator drift

Sensation: intact to light touch in all extremities

Coordination: No finger to nose dysmetria

Gait cautious but well balanced

Incision: c/d/i glue intact

 

Primary Procedures:

Procedure(s):

CRANIOTOMY POSTERIOR FOSSA CP ANGLE TUMOR 

Secondary Procedures:

None 

Reason for Hospital Admission (Admitting Diagnosis):

Skull base tumor, likely epidermoid

 

Complications: none 

Consults:

None

Smoker: No.

 

Condition on Discharge: stable 

Code Status at Time of Discharge: Full Code

 

 

 

H&P

 

History and Physical Note 

ZZZ is a 64 Y male.

 

Chief Complaint:

Dizziness related to brain tumor

 

History of Present Illness:

The encounter is conducted with the assistance of the patient's daughter who acts as a Spanish-speaking interpreter. . 

 

The patient is known to me from a clinic visit in October of 2021 at which time he presented with vertiginous episodes leading to cranial imaging.  He was known to have a small epidermoid back in 2007 but was lost to follow-up and new imaging revealed marked tumor progression in the posterior fossa bilaterally.  I recommended surgery and the patient was considering.

 

More recently, the patient has noted significant progression of symptoms.  The patient describes frequent vertiginous episodes which have been severe enough to result in a recent ED visit.  He also notes significant left sided posterior headaches, blurred vision OS and perhaps some fullness in the left ear.

 

The patient denies hearing loss, diplopia or sensorimotor disturbances in the extremities.

 

A recent audiogram demonstrates excellent bilateral hearing with 100% word recognition AU.

  

Medications Prior to Admission:

•             Atorvastatin (LIPITOR) 40 mg Oral Tab     Take 1 tablet by mouth daily to prevent heart attacks and strokes

•             Lisinopril (PRINIVIL/ZESTRIL) 20 mg Oral Tab         Take 1 tablet by mouth daily

•             OMEPRAZOLE ORAL        Take as directed PRN acid reflux

  

Allergies:

Allergies

Allergen               Reactions

•             No Known Allergies          

                                per UC2 staff

 

 

Past Medical History:

Active Ambulatory Problems

                Diagnosis             Date Noted

•             PREDIABETES     01/07/2008

•             HYPERLIPIDEMIA              01/07/2008

•             GERD (GASTROESOPHAGEAL REFLUX DISEASE)   01/03/2008

•             EPIDERMOID CYST, BRAIN            01/25/2008

•             RIGHT BIMALLEOLAR FX 09/09/2019

•             HX OF CORONAVIRUS COVID-19 DISEASE               02/04/2021

•             INTERNAL HEMORRHOID              06/24/2021

•             OBESITY, BMI 30-34.9, ADULT     09/15/2021

 

No Additional Past Medical History 

 

Past Surgical History:

Past Surgical History:

Procedure           Laterality             Date

•             HEMORRHOIDECTOMY                   

•             ORIF, ANKLE FRACTURE Right      9/13/2019

                Performed by Kraetzer, Bradford Burr (M.D.) at FRE-MAIN-OR

 

 

Social History:

 Social History

 

Tobacco Use

•             Smoking status: Never Smoker

•             Smokeless tobacco:        Never Used

Vaping Use

•             Vaping Use:        Never used

Substance and Sexual Activity

•             Alcohol use:       Yes

                                Alcohol/week:  8.0 - 10.0 standard drinks

                                Types:   8 - 10 Cans of beer per week

•             Drug use:             No

•             Sexual activity:  Yes

                                Partners:             Female

Social History Narrative

                Drives truck for roofing materials

 

 

E-Cigarettes/Vaping

                Questions           Responses

                E-Cigarette/Vaping Use Never User

 

Family History:

Family History

Problem               Relation               Age of Onset

•             Hypertension    Mother  

•             Hypothyroidism Mother  

•             Heart Disease    None      

•             Diabetes              None      

•             Hyperlipidemia None      

•             Colon Cancer     None      

•             Prostate Cancer None      

 

 

Review of Systems:

Negative in detail

 

Objective:

BP 135/83  | Pulse 72  | Temp 97.4 °F (36.3 °C) (Temporal)

 

Physical Exam:

General appearance - alert, well appearing, and in no distress

Mental Status -  alert, oriented x 3

Eyes -  pupils equal and reactive

Neck - supple

Chest - clear to auscultation

Heart - regular rate and rhythm

Abdomen - soft, nontender, nondistended

Neurological - Bright affect, NAD. 

PERRL, EOMI.  No nystagmus

Facial sensation symmetric to LT and PP V1-2-3.

Facial power full and symmetric.

Hearing symmetric to tuning fork, Weber's is midline.

No dysphonia, symmetric elevation of soft palate, ABSENT gag reflex.

SCM/trapezius 5/5 and symmetric.

Tongue protrudes in midline.

No drift, power 5/5 throughout with good dexterity.

Sensation symmetric to all modalities.

No cerebellar findings.

Gait steady with good heel, toe and tandem.  Rhomberg is negative.

 

Selected Results:

Last CBC  No results for input(s): WBC, HGB, HCT, PLT in the last 72 hours.

 

Invalid input(s): MCT

Last Chem 7  No results for input(s): NA, K, CL, CO2, BUN, CR, RBS in the last 72 hours.

Last Coags  No results for input(s): PT, INR, PTT in the last 72 hours.

 

Review of Other Relevant Data:

MRI brain:  Large posterior fossa ventral epidermoid, right greater than left, with extension into right cavernous sinus and suprasellar cistern.  There is bilateral mass effect on the middle cerebellar peduncle.  No subjacent edema is noted and ventricular size is normal

 

Assessment and Plan:

Progressive vestibular symptoms in the setting of an enlarging complex posterior fossa epidermoid tumor.  The patient's complaints lateralize to the left but there are no objective lateralizing findings and the tumor is larger on the right.

I informed the patient that the tumor is benign in nature but that the only treatment option is surgery.  I explained that surgery cannot remove tumor from both sides in a single sitting so I am recommending debulking the tumor on the symptomatic side with likely staged contralateral surgery depending on outcome.

Furthermore, I explained that the goals of surgery are to prevent further symptom progression and to ATTEMPT to improve patient's current vestibular symptoms.

I discussed surgery in detail including rationale, technique, outcomes, risks, benefits and alternatives.  I answered all questions to the patient's apparent satisfaction.  I explained that the largest risk of surgery in his case is that his vestibular symptoms may not necessarily improve.  I also informed patient of my impending retirement and that we will transition his neurosurgical care to my colleague, Dr. AAA.

The patient expressed understanding of the above and gives informed consent to proceed with surgery.

PLAN admission for left suboccipital craniotomy and debulking of epidermoid tumor with electrophysiologic monitoring.

 

Code Status:

Full Code

 I reviewed Meds, Allergies & Problems. 

The total visit time face to face with the patient was over 30 minutes.

Time spent in counseling and discussion with the patient was over 20 minutes.

Topics discussed as noted above.