REASON FOR CONSULTATION: Consult for VP shunt removal and insertion of an external drain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with past history of Chiari I malformation, multiple VP shunts with revision and recent VP shunt revision, and posterior fossa decompression in March (XXXX). The patient is being admitted for possible shunt malfunction and also a surgical site on her scalp opening up/surgical wound dehiscence.
The patient denies any headaches, changes in vision or dizziness. She also denies any fever. No chills. She also denies any chest pain, shortness of breath, nausea or vomiting.
The patient has been doing well. She denies any recent seizures. Last time she had a seizure was approximately a year or so ago. She has been seizure-free on her current antiepileptic medication, Lamictal.
The patient is scheduled to go to the operating room today for VP shunt removal and insertion of an external drain with neurosurgeon, Dr. John Doe. Currently, the patient is resting comfortably.
The patient was ordered vancomycin and Rocephin by Neurosurgery. During her vancomycin infusion, she did complain of redness and flushing of her face and truncal areas and some pruritus. The vancomycin was stopped.
She was prescribed Benadryl, and the above symptoms resolved. Neurosurgery has elected to resume the vancomycin but at a slower pace. They have also prescribed Benadryl.
MEDICAL PROBLEMS: As above.
SURGICAL PROBLEMS: As above. Also strabismus surgery and hernia surgeries.
MEDICATIONS AT HOME: Lamictal 200 mg b.i.d., multivitamin and folic acid.
ALLERGIES: None.
SOCIAL HISTORY: The patient does not drink, smoke or use any drugs.
FAMILY HISTORY: The patient’s father is alive and well with possible brain tumor in the recent past with resection. The patient’s mother is alive and without any problems.
REVIEW OF SYSTEMS: As per the HPI. Remaining 14 systems are negative.
PHYSICAL EXAMINATION: Blood pressure 102/62, pulse 76, respirations 18, temperature afebrile, and she is saturating 100% on room air. The patient is awake, alert and oriented to person, place and time, in no acute distress. Neck: Supple. No thyromegaly. No carotid bruits. Heart: Rhythm is regular. S1 and S2. No murmur, gallops or rubs. No JVD or edema. Lungs: Clear. No rales, rhonchi or wheezing. Gastrointestinal: Abdomen is soft and nontender. Positive bowel sounds. Neurologic: Cranial nerves, muscle strength, and sensory exam are all grossly intact.
DIAGNOSTIC DATA: CT of the brain shows right parietal VP shunt with tip in the left paramidline, mid sagittal space, just superior to the third ventricle. There is a curvilinear density adjacent to this, which may represent calcification versus small amount of hemorrhage. There is no hydrocephalus. There are no acute intracranial abnormalities noted.
ASSESSMENT:
1. The patient is being admitted for ventriculoperitoneal shunt removal and insertion of external drain secondary to possible shunt malfunction and surgical wound dehiscence.
2. History of Chiari I malformation, multiple ventriculoperitoneal shunt revisions, posterior fossa decompression and seizure disorder.
3. Reaction to vancomycin IV infusion.
PLAN:
1. To OR today.
2. Resume home medications.
3. Follow up a.m. labs.
4. We will resume the vancomycin at a slower IV infusion rate and also use Benadryl p.r.n. We will check with pharmacy about this. We will also monitor for any further reactions. If the patient continues to have the reaction, we will discuss the case rather with Neurosurgery and see if there is an alternative antibiotic that we can give instead of vancomycin. All questions have been answered. We have discussed the case with the patient and her family. All agreed with the plan of care.
Thank you for the consult. We will follow along with you.
