DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSIS: Alcohol-induced seizure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who was admitted for witnessed seizure at the beach. The patient states this is one of multiple seizures he gets when he is drinking alcohol. The patient admitted to being intoxicated at the time of the admission. The patient’s last visit to his primary care physician was two years prior.
PAST MEDICAL HISTORY: Hypertension and alcohol abuse.
CURRENT MEDICATIONS: The patient is presently taking no medications.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient states he still works. He has a history of tobacco abuse and alcohol abuse. The patient lives alone. He has children who live locally and his brother who lives locally.
REVIEW OF SYSTEMS: Remarkable for productive cough and dysuria.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 188/98 on admission. GENERAL APPEARANCE: The patient is alert, intact, with no cognitive impairment. HEENT: Atraumatic and normocephalic. The patient has poor dentition. NECK: There is no JVD, bruits or thyromegaly. HEART: Regular rhythm. LUNGS: Clear. ABDOMEN: Soft and nontender without masses. EXTREMITIES: Without edema.
LABORATORY DATA: Sodium 146, potassium 3.8, chloride 108, bicarbonate 20, BUN 13, creatinine 1.7, blood sugar 120. White count 7700, hemoglobin 12, and platelets 278,000. CPK is 216. Troponin is less than 0.1. Alcohol level was 214.
DIAGNOSTIC DATA: EKG revealed a right bundle block. Chest x-ray was unremarkable. Urine tox screen was positive only for alcohol.
HOSPITAL COURSE: The patient was started on intravenous thiamine, multivitamin, and Ativan p.r.n., watched for alcohol withdrawal, and hydrated. He was started on a beta-blocker for his hypertension and Levaquin for what resulted in a positive urinalysis. There was no reported seizure activity, and the patient remained cognitively intact. The patient’s blood pressure was further controlled with Norvasc 10 mg. The patient was discharged in stable condition to follow up with us as an outpatient, given two weeks of prescription, and should follow up with us for samples.
