CHIEF COMPLAINT: Seizure activity.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presents to the emergency room today with about a three-year history of seizure. Her husband is present at bedside and states that she has been having increasing seizures lately. She states that she had a seizure on Sunday, Monday, and today, which is Tuesday. She has seen her primary care physician recently who has recently increased her Trileptal. She did not come to the emergency room after the previous surgery. She was in the emergency room earlier this month for chest pain and shortness of breath. She apparently has a chronic history of musculoskeletal chest pain. She is asymptomatic in that regard at this time. She was seen previously for a possible seizure, and at that time, a CT scan was done, and it showed no evidence of acute intracranial process. She did have mild frontal lobe atrophy. There was no bleed noted.
PAST MEDICAL HISTORY:
1. Seizure disorder.
2. Chronic chest pain.
3. Chronic back pain.
4. Anxiety.
5. Depression.
6. Coronary disease with history of subclinical myocardial infarction.
SOCIAL HISTORY: The patient denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS:
1. Trileptal, the dose was recently increased.
2. Promethazine 25 mg as needed.
3. Percocet two tablets three times daily.
4. OxyContin 80 mg twice daily.
5. Cymbalta 60 mg daily.
ALLERGIES: NO DRUG ALLERGIES.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 142/86, pulse 98, respirations 18, temperature 97.8, and O2 sat is 97% on room air.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy, no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact. Her neurologic examination is abnormal, the fact that she has poor short-term memory. She does not recall much about today’s activities.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated for possible seizure activity. Her family is present at bedside and states that she has not been acting herself since the seizure. This has happened to her in the past. She sounds as though she may be having partial seizures or absence seizures where she stares off into the distance and in addition to grand mal seizures that she has had in the past. She does follow up with a neurologist regularly who has increased her dose of Trileptal recently. She certainly is not convulsing at this time. Blood work was done. CBC is negative with a normal white count. Electrolytes panel was drawn. Sodium and potassium were both normal. BUN and creatinine are within normal limits. Her sugar was normal. There is no evidence of any specific trigger for her seizures. As mentioned, she did have a CT scan of her brain earlier this year. She has had no trauma since then. She has been afebrile since then. She does follow up with a neurologist regularly. At this time, she is stable for discharge to follow up with her primary care physician or neurologist.
DISCHARGE DIAGNOSIS: Seizure activity.
PLAN:
1. She should continue same medications as recommended by her neurologist.
2. She should contact her neurologist tomorrow for followup care.
3. Return to the emergency room if she has any headache, blurred vision, nausea, vomiting or any type of neurologic symptoms.
Otherwise, she does not require any prescription. At this time, she can continue taking what she already is on.
DISPOSITION: The patient was discharged to home in stable condition.
