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.
