IP-17.pdf - IP Encounter Report MRN DOB Adm Sex M D/C...

Unformatted text preview: IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Admission Information - Hospital Account/Patient Record Arrival Date/Time: Admission Type: Means of Arrival: Transfer Source: None Elective Walk In None Admit Date/Time: Point of Origin: Primary Service: Service Area: Admit Provider: Mourani, Peter M. Attending Provider: 7:48 AM Clinic Or Physician Office Rehabilitation The Children's Hospital (Sa) Wilson, Pamela E. IP Adm. Date/Time: Admit Category: Secondary Service: Unit: None None Eight West 7:48 AM Referring Provider: None Discharge Information - Hospital Account/Patient Record Discharge Date/Time 12:50 PM Discharge Disposition Dc To Home Or Self Care (Routine Disch) Discharge Destination Home Discharge Provider Wilson, Pamela E. Unit Eight West ED Arrival Information Patient not seen in ED ED Disposition None Hospital Problems Reviewed: Diabetes mellitus type I Codes 250.01 Unspecified epilepsy with intractable epilepsy 345.91 Right sided weakness 728.87 Developmental disability 315.9 Overview Signed Priority Class 9:27 PM by Hazleton, Joy Noted - Resolved POA - Present Yes Entered by Heavilin, Nancy D. - Present Yes Entered by Heavilin, Nancy D. - Present Yes Entered by Heavilin, Nancy D. - Present Yes Entered by Maahs, David M. 11:08 AM by Maahs, David M. Requires further evaluation. Father holds child by arm and says he 'can't let him go or he will hurt himself' Non-Hospital Problems Reviewed: Exotropia, unspecified Codes 378.10 Amblyopia 368.00 Valproic acid toxicity E936.3 Priority Class 9:27 PM by Hazleton, Joy Noted - Resolved - Present Entered by Parsons, Julie A. - Present Entered by Mets, Rebecca B. - Present Entered by Hazleton, Joy Discharge Summaries - All Notes Discharge Summaries signed by Dise-Lewis, Jeanne E. at Author: Dise-Lewis, Jeanne E. Service: Filed: 3:34 PM Note Time: Related Notes: Original Note by Negron, Javier I. filed at 3:34 PM (none) Author Type: Rehab Psychologist 5:42 PM 1:10 PM REHABILITATION PSYCHOLOGY DISCHARGE SUMMARY Name: MRN: Birthdate: Age: 9 year 6 month old Language: Somali Date of admission to Neurotrauma/Rehabilitation Inpatient Unit: Date of Report: (MR # Printed by [103311] at 10/11/13 10:56 AM Page 1 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) PRESENTING SITUATION: is a 9 year old boy who was treated as an inpatient at on the Neurotrauma/Rehabilitation program from to following a hemispherectomy on has been seen through the Psychology Programs in the Department of Rehabilitation Medicine for Health and Behavior Interventions to assess and treat biopsychosocial factors affecting his medical recovery, in particular his adjustment to hospitalization, treatment and rehabilitation. NEUROCOGNITIVE STATUS: In the Rehabilitation Psychology Initial Assessment, pre-injury cognitive development was reported to be significantly impaired for his age. His father reports normal development and health until 3 years of age when he became quite ill with high fevers and subsequent coma. He was diagnosed with type 1 diabetes. was then hospitalized and began having seizures during this time. The family was subsequently placed in a refugee camp and cared for there until coming to the United States in of Initially his seizures occurred a few times per week but rapidly increased to several daily, despite medications. Since his arrival in the U.S., he has had multiple admissions for status epilepticus. During his initial hospitalization following his surgery, had a prolonged period of generalized lack of arousal and orientation. His initial score on the COAT was in the significantly impaired range, indicating deficient overall orientation. was unable to answer any questions and/or follow any commands. At discharge, his score on the COAT was also in the significantly impaired range, indicating deficient overall orientation. A neurocognitive screening /evaluation was conducted on . Procedures used included Wechsler Abbreviated Intelligence Scale (WASI-2), Symbol Search and Digit Span. However, was unable to complete any of the tests even when provided with multiple cues and support. Results of evaluation and interpretations: Behavior: had considerable difficulty participating in this evaluation. The entire assessment was done with his father and interpreter. had significant difficulty engaging in the assessment. Multiple attempts were made to describe and help understand instructions to tasks. However, was unable to learn how to perform the different tasks. For example, he was unable to do any of the following: name objects in a picture, point to a picture to match with others, and/or draw a line over similar symbols. had significant difficulties understanding what he was being asked to do. He demonstrated an impulsive response style and appeared to have considerable difficulty understanding the task at hand. He demonstrated good general effort, but did not understand what was being asked of him. This evaluation is believed to adequately represent current neurocognitive abilities. General cognitive abilities: cognitive abilities appear to be significantly and globally impaired. He will require a high level of support in order to promote a successful return to school. Proactive home/school communication will be essential to provide a context for new learning. Attention and working memory: Attention is made up of various components including selective, sustained, and divided attention. Selective attention refers to the ability to focus on relevant information and ignore irrelevant information. Sustained attention refers to the ability to maintain attention over extended periods of time. Divided attention refers to the ability to successfully attend to more than one feature or aspect at a time. Significant difficulties across all areas of attention were noted. requires constant support and cues to pay attention to any particular task. He is also easily distracted as in unable to sustain his attention without significant support. is easily distracted by both internal and external stimuli. was able to repeat some words in English and Somali, but he was unable to repeat a list of numbers. Even when provided with objects to point to, in order to assess working memory without requiring him to answer verbally, he was unable to perform this task. (MR # Printed by [103311] at 10/11/13 10:56 AM Page 2 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) Mental processing speed: Mental processing speed is the rate at which we take in, understand, integrate and respond to information. It is an indicator of overall brain functioning efficiency that is highly sensitive to injury. speed of mental processing has been significantly affected by his injury, as expected given his significant cognitive impairments. New learning and memory: ability to learn and recall newly learned information is severely impaired. He was unable to repeat information regardless if it was given to him in English or Somali. He was able to learn and recall one phrase in Somali used during a group activity. I had asked the interpreter how to say "good job" in Somali. Whenever did something well, I used this phrase. From that moment on, use this phrase whenever he saw me. is capable of learning and retaining information, if provided and practiced in rote fashion. Social/Emotional status Throughout his rehabilitation stay, emotional presentation was predominately relaxed and friendly, because he was with family members during the entire stay. Due to his extreme level of cognitive impairment, will need to have careful attention paid to familiarizing him with new environments and people. Slow and supported exposure to new people, positive reinforcement and encouragement have been helpful. SUMMARY and RECOMMENDATIONS 1. neurocognitive abilities are significantly affected at present and he demonstrates diminished overall verbal, visual-perceptual, new learning, memory and attention abilities. He has significant reduced speed of processing at the current time. Easy fatigability should be expected when he returns to more stimulating and busy home and school environments. 2. It is recommended that gradually increase his level of participation in his typical activities, including return to school. The best situation for children and their families, during this important transition home, is a well educated and well-functioning parent school team. Recommendation specific to current needs are included at the end of this report in the section titled Return to School. Finally, Medical Discharge, Occupational Therapy, Physical Therapy and Speech-Language reports include assessment information and further recommendation, including physical activity restrictions, for consideration in planning his successful return to school. will return to Children's Hospital Colorado's Rehabilitation clinic on and his Neurology physician for his one-month follow up appointments. at 8:30am to meet with me A more comprehensive evaluation through the Multidisciplinary Outpatient Rehabilitation Evaluation (M.O.R.E.) Team in the Department of Rehabilitation of is recommended in one year in order to attain an updated assessment of neurocognitive profile and offer consultation/recommendations. Please contact Chris Moores at (720-777-5470) to schedule an appointment for the next year. It was a pleasure working with and his parents during his hospital stay. I will look forward to meeting with them one month following his discharge, on . Please do not hesitate to contact me or bring questions/concerns to be discussed at this appointment. I am happy to be available for consultation or questions at 720-777-3901 or [email protected] Javier Negron, Psy.D. 720-777-3901 (MR # Printed by [103311] at 10/11/13 10:56 AM Page 3 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) [email protected] Jeanne E. Dise-Lewis, Ph.D. Supervising Clinical Psychologist 720-777-6642 [email protected] RETURN TO SCHOOL PROTOCOL Schedule and timing: should re-enter school gradually starting with a few hours per day, increasing to a half day and progressing to a full day as he tolerates it. IEP: will require significant Special Education support. parents and school personnel are encouraged to meet to develop IEP (Individualized Education Plan) before his return to school to identify the appropriate school program for his level of needs. Academic overview: Currently, does not demonstrate any preschool level concepts, nor does he clearly benefit from modeling of skills. He requires a classroom setting that provides maximal supports. Proactive home/school communication will be essential in developing a safe and accessible learning environment for at school. Electronically signed by Negron, Javier I. at Electronically signed by Dise-Lewis, Jeanne E. at 1:10 PM 3:34 PM Discharge Summaries signed by Dichiaro, Michael R. at Author: Dichiaro, Michael R. Service: Filed: 10:04 PM Note Time: Related Notes: Original Note by Kanallakan, Amy S. filed at 10:04 PM Rehabilitation 1:32 PM 10:01 PM Author Type: Physician Rehab Medical Discharge Summary Patient Name: Admit: (MR # Printed by [103311] at 10/11/13 10:56 AM Page 4 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) Discharge: Attending: Wilson, Pamela E. (contact through One Call 720-777-3999) Referring Physician: No ref. provider found PCP: David Fox, M.D. Diagnoses: Principal/Final Diagnosis: Right sided hemiparesis Secondary Diagnoses: Seizure disorder (Lennox-Gastaut Syndrome with intractable seizures), Type 1 Diabetes mellitus, mobility impairment, speech impairment, s/p left functional hemispherectomy Next Steps for PCP: Pending Labs/Procedures: Pending Studies (Results not Final) (Last 100 days) ** None ** Significant Findings Requiring Outpatient Followup: Blood glucose management, medications for home (please review), Vitamin D (off Vit D therapy since expensive) Brief Reason for Hospitalization: is a 9 year old male admitted on for Seizure disorder [345.90] Please refer to H+P note for complete details of presenting illness. The patient was admitted to the hospital on and taken to the operating room that day where he underwent an uncomplicated left functional hemispherectomy. He tolerated the procedure well and was managed initially in the PICU. Endocrine was consulted and involved with the management of his diabetes and insulin dosing. An EVD was placed at the time of surgery. He stayed in PICU until POD #2 secondary to poor glucose control. Unable take po initially so NG placed and tube feedings started. His right hemiparesis was dense postoperatively, with a right facial, but did begin to show signs of movement (especially with unintentional movement). PT and OT were involved. His incision was healing well. He mobilized. He remained afebrile. He had no seizures. He tolerated his tube feeds but did have tenuous glucose control with tube feedings. On POD #7-8 he began to take po much better so NG feeds were held and he took all nourishment by mouth. This also resulted in improved glucose control. His EVD was raised on POD #6 and clamped on POD #7. MRI shunt series on POD #8 showed stable vents and expected postop change. His EVD was removed. He continued to do well without seizures, fevers, or leaks from drain site or incision. He had just a small subgaleal fluid collection. He was ready for transfer to the inpatient Rehab service. Brief Hospital Course (summary of care, services provided and significant findings): Acute course: The patient was admitted to the hospital on and taken to the operating room that day where he underwent an uncomplicated left functional hemispherectomy. He tolerated the procedure well and was managed initially in the PICU. Endocrine was consulted and involved with the management of his diabetes and insulin dosing. An EVD was placed at the time of surgery. He stayed in PICU until POD #2 secondary to poor glucose control. Unable take po initially so NG placed and tube feedings started. His right hemiparesis was dense postoperatively, with a right facial, but did begin to show signs of movement (especially with unintentional movement). PT and OT were involved. His incision was healing well. He mobilized. He remained afebrile. He had no seizures. He tolerated his tube feeds but did have tenuous glucose control with tube feedings. On POD #7-8 he began to take po much better so NG feeds were held and he took all nourishment by mouth. This also resulted in improved glucose control. His EVD was raised on POD #6 and clamped on POD #7. MRI shunt series on POD #8 showed stable vents and expected postop change. His EVD was removed. He continued to do well without seizures, fevers, or leaks from drain site or incision. He had just a small subgaleal fluid collection. He was ready for transfer to the inpatient Rehab service. (MR # Printed by [103311] at 10/11/13 10:56 AM Page 5 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) Acute rehabilitation: is a 9 year old male with history of intermittently controlled type 1 DM, remote history of extensive left hemispheric infarction resulting in right hemiparesis and focal epilepsy with multiple seizure types s/p left functional hemispherectomy and microsurgical temporal lobectomy on with Dr. Handler resulting in worsening right hemiparesis. Current functional deficits include impaired mobility, ability to participate in ageappropriate ADL's/play, speech/cognition and ability to tolerate oral intake. Seizures continue to be sporadic, none in 48 hours, on increased clobazam, EMU team following. Blood glucoses and T1DM with variable control; Endocrine service assisting with management. Rehab Course: 1. Functional deficits include impaired mobility, ability to participate in age-appropriate ADL's/play, speech/cognition and ability to tolerate oral intake. 1. Continue acute inpatient rehabilitation service for continued medical management, 24-hour nursing, intensive therapies with PT, OT and SLP and continued patient/family education. 2. Tone: Mild hypertonicity noted will continue to monitor; no tone meds 3. Orthotics: Solid right AFO to assist with ambulation; will continue to monitor for progression; LUE brace per OT 4. Equipment: Will follow progress with therapies. 2. Seizure disorder 1. Currently on clobazam, valproic acid and zonisamide - continue to monitor closely for seizures. s/p video EEG on . Loaded with Fosphenytoin ; s/p Diastat rectal ; load with lorazepam 0.1mg/kg IV x1 on and increased clobazam. 2. EMU managing AED's. Per EMU team: 1. MRI brain without contrast completed on 2. Continue anti-epileptic medications as follows: 1. Valproic Acid 500mg qAM, 500mg qnoon, 750mg qhs 2. Zonisamide 200mg qHS 3. Clobazam 15mg BID (last increased dose ) 3. In case of prolonged seizure, the following rescue plan is in place: 1. diazepam 5mg PR x1 for seizure > 5 minutes or clustering; 2. If needing to use the PR rescue medication, then replace PIV (last placed ). 3. PIV PRNs on MAR: 1. Lorazepam 0.1 mg/kg/dose IV PRN generalized seizure lasting > 5 min or focal seizure lasting > 10 min, may repeat x 1 in 5 minutes if necessary 2. Fosphenytoin 20 PE/kg/dose IV PRN status epilepticus 3. FEN: NGT out since , s/p calorie count. 1. Regular diabetic diet with thin liquids 2. Vitamin D 25-OH < 30 on ; started cholecalciferol 4000 units daily on . Repeat vitamin D 25-OH in mid. Father unable to fill expensive cholecalciferol prescription. Will alert Special Care Clinic if they are aware of a cheaper Vit D alternative. 4. Type 1 DM: Blood glucose levels difficult to control. Endocrine followed and we used Lantus in the AM with Humalog carb counting and correction during admission. 1. IgA, TTG IgA per Endo request 2. D/C medication plan is Insulin 70/30 11 Units in AM (down from 15 prior), 6 Units in PM 5. Pain: 1. Tylenol and ibuprofen PRN 2. Stopped gabapentin 100 mg TID , since no pain (had been on it since - not for sz but for pain) 6. GI: 1. Continue daily Miralax; PRN docusate and bisacodyl suppository available 2. d/c'd ranitidine on (MR # Printed by [103311] at 10/11/13 10:56 AM Page 6 IP Encounter Report MRN: DOB: Adm: Sex: M D/C: Discharge Summaries - All Notes (continued) 7. Discharge planning: 1. Care conference: completed at 12pm Operative Procedures: resection of seizure focus Allergies: No Known Allergies 24 hr Events/Discharge Exam: Events in last 24 hours: No -Vital signs over the last 24 hours were reviewed . -Intake and output for the last 24 hours were reviewed and demonstrate Fluid balance- relatively even BP 129/67 | Pulse 96 | Temp 35.3 | Resp 20 | Ht 129 cm | Wt 27.8 kg | SpO2 97% Oxygen:RA Wt. (Current): 28 kg General: Awake, alert, NAD HEENT: Well healing surgical scars on scalp, conjunctiva clear, no rhinorrhea, MMM Neck: there is full active range of motion Chest: breath sounds are CTA bilaterally without rales, rhonchi, or wheezes. Cardiac: RRR, normal S1 and S2 Abdomen: abdomen is soft, nontender, and nondistended Skin: warm, well perfused, no rashes Musculoskeletal/Ext: no cyanosis, clubbing, or edema, no joint tenderness or swelling Central Nervous System: Awake and alert, vocalizing and interactive, telling jokes, hemifacial flattening. Antigravity Right LE HF and KE, no active dorsiflexion. Little spontaneous RUE movement. RUE with mildly increased tone, MAS 1 in finger flexors, wrist, EF. Reflexes 2+ UE bilaterally; 3+ patellar reflex on right, 2+ on left. 2 beats clonus bilaterally at achillies. Able to walk with assist, knee extension moment notes, foot drop. Functional Ability Observed: 70% - both grater restriction of and less time spent in play activity General Discharge Information: Condition on Discharge: Good Discharge Disposition: Discharged to: Home Discharge Medications and Treatments: Medications To B...
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