DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSIS: C3 through C7 spondylosis with myelopathy.
DISCHARGE DIAGNOSIS: C3 through C7 spondylosis with myelopathy.
PROCEDURE PERFORMED: Stage I C3 through C7 anterior cervical discectomy and fusion with plating. Planned stage II C3 through C7 redo decompression posterior fusion.
HOSPITAL COURSE: The patient is a (XX)-year-old male admitted with the above diagnosis. The patient was taken to the operating room first on MM/DD/YYYY and then on MM/DD/YYYY to undergo the above-stated surgical procedures. The patient tolerated these procedures well and postoperatively was extubated and taken to the recovery room in stable condition.
Once in the recovery room, the patient continued to do well. He became more awake and alert and soon was moving all extremities. The patient had no difficulty swallowing or with respirations. He was slightly hoarse but was afebrile with stable vital signs and moving all extremities well. The patient was then transferred to the neurologic intensive care unit where he remained in stable condition.
Neurologically, the patient remained stable. His Hemovac drain, Foley catheter, and PCA pump were eventually discontinued. His anterior and posterior incisions remained clean and dry and dressing was intact. The patient was seen by Physical and Occupational Therapy. The patient denied radicular pain, numbness or tingling. The patient continued to mobilize with physical therapy assistance. The patient did have some pre-existing right-sided weakness, which persisted after surgery. He was walking with a walker and continued to progress with this. The patient was seen by Respiratory Therapy for rhonchi and wheezing in his chest. The patient was also seen by the medical service for this. The patient had no neurologic complaints and continued to progress.
He was soon evaluated and found to be fit for discharge to an inpatient rehab facility. Once medically stable, the patient was cleared for transfer and was discharged in stable condition with family and the appropriate followup appointment scheduled. During his stay, the patient also received IV antibiotics through a peripherally inserted central catheter.
DISCHARGE CONDITION: Stable.
DISPOSITION: Inpatient rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient will follow up in the office in two to three weeks. Wound care, activity, and other instructions as well as pain medication prescriptions have been given for discharge. The patient and his family understand that they are to call the office in the interim if any problems or questions prior to followup visit arise.
