REASON FOR ADMISSION: Rehabilitation status post evacuation of brain tumor (glioblastoma multiforme).
ADMISSION DIAGNOSES:
1. Status post excision of glioblastoma multiforme brain tumor.
2. Right hemiparesis.
3. Obesity.
4. Seizure disorder.
5. Hypertension.
6. Hypercholesterolemia.
DISCHARGE DIAGNOSES:
1. Status post excision of glioblastoma multiforme brain tumor.
2. Right hemiparesis.
3. Obesity.
4. Seizure disorder.
5. Hypertension.
6. Hypercholesterolemia.
7. Recurrent seizures.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who was hospitalized following episode of multiple seizures. The patient’s symptoms were similar to a cerebrovascular accident. The patient presented with unilateral right arm and leg involvement, involuntary spasms and weakness. The patient underwent multiple studies, including CT and MRI, which were suggestive of stroke. The patient was admitted and began program of stroke rehabilitation. His condition improved for a short period of time but then he began declining in his functional mobility with more frequent episodes of seizures. The patient’s seizures were not responsive to adjustment of medications, and the patient was sent for repeat MRI. Findings were consistent with a mass. The mass appeared to be glioblastoma multiforme in the left parietal region.
The patient was then transferred emergently to an outside hospital for further evaluation by a neurosurgeon. Following neurosurgical consultation, it was felt that the patient would require excision of a 2 x 4 cm enhancing lesion in the left parietal region. The patient was subsequently brought to the operating theater where he underwent image-guided left parietal craniotomy and removal of the primary brain tumor, presumably glioblastoma multiforme. The patient tolerated the surgery well and had significant decline in his self-care and mobility skills. It was felt that the patient would require additional training, strengthening and conditioning prior to beginning chemotherapy and radiation treatment. He was then transferred here for continuation of his care.
HOSPITAL COURSE: The patient was started on a full program of physical and occupational therapy and rehabilitation nursing and did well following his initial evaluations. On MM/DD/YYYY, however, the patient was much more drowsy and had an episode of seizure and decreased overall alertness. Due to the patient’s poor responsiveness, he was sent to the emergency room for further evaluation. He was also noted to be hypotensive and he was started on normal saline at 100 mL. The patient was discharged.
CONDITION: Guarded.
DISCHARGE MEDICATIONS: He will continue with his current medications.
FOLLOWUP: The patient will be followed by Dr. John Doe and his primary medical doctor.
DISCHARGE EQUIPMENT: No equipment was issued with the patient.
