allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from s/p mva ? hemorrhage and cerebellar mass major surgical or invasive procedure: intubation for mri due to severe claustrophobia r suboccipital crani for mass resection history of present illness: mr is 66 y/o male with htn, cad and pad. was in his normal state of health today, with the exception of feeling exausted after being up for 72 hours trying to pump out his basement. he remembers going to and leaving the parking lot that is the last thing he remembers. he awoke with the arrival of the ems, he was found in the parking lot the details of what he hit are unavailable and there is discrepancy about whether the air bag deployed. he was brought to hospital and found to have ? cerebellar mass versus stroke and right occiptal partieal focus of iph. these appear to be more concerning for masses than trauma. the patient only complains of low back pain at this time. past medical history: cad, pad, has had right iliac artery stent and right coronary artery stent social history: former smoker 60 pack year hx stopped in . drinks 3-4 glasses of wine per day. no illicit drug uses. lives with wife, works part time installing fire suppression systems. family history: non-contributory physical exam: upon admission: bp:150/81 hr:80 r 18 o2sats 98% gen: wd/wn c/o back pain heent: pupils: eoms full; neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light,4 to 3 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. no pronator drift motor: d b t ip q h at g r 5 5 5 3 5 5 5 5 5 l 5 5 5 3 5 5 5 5 5 note ip most likely limited by pain sensation: intact to light touch reflexes: b t br pa ac right 2+ left 2+ toes downgoing bilaterally coordination: normal on finger-nose-finger, unable to test heel to shin due to back pain. patient did not want me to turn him according to trauma there was lumbar point tenderness. no bowel or bladder incontinence upon discharge: same as above. neurologically intact. incision clean, dry, and intact pertinent results: ct abdomen with contrast : 1. age-indeterminate l3 and l4 compression fractures. recommend clinical correlation. no evidence of acute visceral injury in the abdomen or pelvis. 2. esophageal wall thickening and regional gastrohepatic lymphadenopathy. recommend endoscopy for further evaluation. follow-up and further evaluation for cause of lymaphdenopathy should be obtained if endoscopy is negative and no other source identified. 3. right lower lobe pulmonary nodule measure up to 6-mm. recommend dedicated chest ct for further evaluation. six-month followup ct should also be performed to assess stability, given patient's smoking history. 4. hypodense hepatic lesion in segment iv. recommend ultrasound or mri for further characterization. mri brain : numerous enhancing masses throughout the supra- and infratentorial compartments, without subependymal or leptomeningeal enhancement. the findings most likely represent multiple metastatic lesions, likely mucinous adenocarcinoma from a gastrointestinal primary site, given the mr , as well as the findings on the body ct scan. ct chest with contrast : 1. right middle lobe lung nodule. followup in three months is recommended. 2. fatty liver with a focal lesion in the left lobe of the liver. as recommended in prior ct abdomen, mr could be performed. 3. soft tissue asymmetry in the right side at the level of the cricoid. this can be evaluated either with physical exam or endoscopy. 4. regional gastrohepatic lymphadenopathy associated with esophageal wall thickening as mentioned in prior ct should be evaluated. 5. coronary calcifications. ultrasound of the liver : 1. no liver lesion to correlate with hypodensity seen on ct scan identified. no worrisome lesions identified. 2. echogenic liver consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. mri l-spine with and without contrast : 1. multiple subacute compression fractures throughout the visualized thoracolumbar spine, corresponding to the findings on the prompting ct scan. there is no associated soft tissue mass and there is some normal residual bone marrow within each vertebral body. both the mr appearance suggests that these are most likely "benign" osteoporotic fractures, without features suspicious for malignant involvement. 2. chronic bilateral l5 spondylolysis with associated grade i anterolisthesis as detailed, and resultant foraminal narrowing, more significant on the right. mri brain : 1. multiple enhancing lesions, in the brain and the cerebral and the cerebellar hemispheres, redemonstrated for surgical planning; the largest lesion in the right cerebellar hemisphere measures 2.5 x 2.6 x 2.0 cm. there has been interval evolution of the lesions, with increased necrosis and more conspicuous rim enhancement on the present study compared to the prior study of , several new lesions compared to the prior study of . this is a limited study, performed for pre-surgical planning. complete smr tudy is recommended to assess betetr the interval change/progression. labs: amdission: 01:41pm wbc-13.6*# rbc-4.38* hgb-11.3* hct-34.3* mcv-78*# mch-25.8*# mchc-33.0 rdw-13.5 01:41pm pt-13.7* ptt-28.1 inr(pt)-1.2* 01:41pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 03:00pm glucose-135* urea n-7 creat-0.7 sodium-123* potassium-3.9 chloride-87* total co2-29 anion gap-11 discharge: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:50am 10.5 4.23* 10.3* 32.9* 78* 24.4* 31.3 13.6 421 renal & glucose glucose urean creat na k cl hco3 angap 05:50am 991 12 0.6 130* 4.8 94* 27 14 brief hospital course: the patient was transferred to from an outside hospital for evaluation of multiple intracranial massess after an episode of loc. additional work up from the osh included a ct of the chest/abdomen that revealed a hypodensity in the liver and a chronic l2 compression fractures. he was hyponatremic upon admission and was admitted to the icu for q1 hour neuro checks and q4 hr sodium checks. his neurologic examination was notable only for mild dysmetria on his right upper extremity. the patient was placed on hypertonic saline for the first night and was switched to salt tablets on when his na was 130. a brain mri was required for the work up but the patient could not tolerate the study due to severe claustrophobia. ultimately, he required intubation for the study. the mri revealed multiple brain lesions. mri of the lumbar spine was negative for any metastasis. additionally, he had a liver ultrasound to further evaluate a hypodensity seen on ct scan. the ultrasound was negative for any concerning lesions. the case was reviewed in the btc. it was felt that the right cerebellar lesion was of a sufficient size as to warrant resection before whole brain radation can be safely administered. since the patient had been on asa, the plan was to discharge the patient to have him return as an outpatient for his surgery. however, the patient failed pt eval, requiring additional hospital stay. ultimately, the patient was taken to the or prior to discharge. on , the patient underwent a right suboccipital craniotomy for tumor resection. he tolerated the procedure well. he was closely monitered in the icu for the following 36 hours and then transferred to to the floor. post-operatively, he remained neurologically unchanged relative to his preoperative examination. he was oob independently and had very little post operative pain. he was seen by physical therapy, who recommended that he was fine to return to home without services. he was discharged to home on . appointments were made for the patient in terms of radiation therapy and gi endoscopy in accordance to the patient's request. he will follow up with dr. office in weeks. he will resume his asa use 1 month after surgery. medications on admission: asa 325mg, diova 160mg qd, lopressor 50mg , vitoran 1080 qd discharge medications: 1. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 2. levetiracetam 750 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for headache. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 6. meds please continue to take your home medications diovan and vytorin. discharge disposition: home with service facility: vna of the discharge diagnosis: multiple brain lesions cerebellar mass - metastesis of unknown origin siadh discharge condition: neurologically stable discharge instructions: 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. ?????? 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. ?????? your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? 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. for one month ?????? 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. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: you have an appointment in the brain clinic on at 2:00pm. the brain clinic is located on the of , in the building, . their phone number is . please call if you need to change your appointment, or require additional directions. be sure you notify your primary care doctor regarding the pulmonary nodule that was found on your chest ct. you should have a repeat ct of your lungs in 3 months. also, you should have a repeat check of your sodium level next week with your pcp. should stay on a strict 1.2l fluid restriction until you see him/her. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Intracerebral hemorrhage Secondary malignant neoplasm of brain and spinal cord Other isolated or specific phobias Other disorders of neurohypophysis Other malignant neoplasm without specification of site Pathologic fracture of vertebrae