Seizure Disorder Discharge Summary Example Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSIS: Seizure disorder.
DISCHARGE DIAGNOSES:
1. Seizure disorder.
2. Dilantin toxicity.
3. Chronic obstructive asthma.
4. Hypothyroidism.
5. Diabetes type 2, uncontrolled.
6. Coronary artery disease of the native vessels.
7. Paranoid state.
CONSULTING PHYSICIAN: John Doe, MD, Neurology.
BRIEF HISTORY: The patient is a (XX)-year-old female who was admitted through the ER after family brought her in, stating that she was hallucinating at home. The patient stated that someone was pushing her and she fell and had abrasions to her lip. Her Dilantin level on admission was 44, and within 24 hours, it was 34.8. She was seen by Neurology, who took her off Dilantin and started her on Keppra 500 mg p.o. b.i.d. for a week and then 1000 mg p.o. b.i.d. afterwards. Dilantin was discontinued. The patient’s mental status did improve. She expressed not hallucinations but more her cultural beliefs and superstitious beliefs. We did get this information via a Spanish translator, which is the language that she speaks.
On the day of discharge, she was ambulating without difficulty. If anything, she would need a walker for stability at home. She was cleared by Physical Therapy and determined to be safe at home. Her seizure disorder remained stable. She did not have any active seizures. Her hypertension was mildly uncontrolled with a systolic of 150, which needs to be monitored and medications adjusted as an outpatient. For her hypothyroidism, we continued Synthroid. Once again, for her seizure disorder, we switched Dilantin to Keppra.
PHYSICAL EXAMINATION: Vital Signs: On the day of discharge, her blood pressure was 154/78, pulse 84, temperature 98, respiratory rate 20, saturating 100% on room air.
DISCHARGE MEDICATIONS: Keppra 500 mg twice a day for the first week and then 1000 mg twice a day thereafter, Synthroid 0.075 mg p.o. daily, and folic acid 1 mg p.o. daily.
DISCHARGE INSTRUCTIONS: The patient will also follow up with her primary care physician.
