DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. New onset seizure.
2. Hypertension.
3. History of Parkinson disease.
4. Urinary tract infection.
5. Hypomagnesemia.
6. Debility.
7. Macular degeneration.
8. Osteoporosis.
9. History of prostate carcinoma.
10. Spinal stenosis.
11. History of cerebrovascular accident.
CONSULTANTS:
1. John Doe, MD
2. Jane Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who presented with new onset of seizure. He was at his breakfast and then about two hours afterwards had a tonic-clonic seizure, which lasted a few seconds associated with incontinence.
HOSPITAL COURSE: The patient was brought in. An EEG was obtained, and the neurology service was consulted. His initial magnesium was 1.5, which was low and this was supplemented. His initial troponin was 0.1. His hemoglobin was 10.2 initially with WBC of 4.8 and platelet count of 140. Initial electrolytes were fairly unremarkable. BUN was 21. The rest of his CMP was within normal limits. Urinalysis had pyuria. Urine culture was positive for Escherichia coli. He has been started on Levaquin.
Initial CT of the head in the ER did not show any acute abnormalities; it did, however, show chronic white matter ischemic changes and atrophy. MRI of the brain was obtained. MRI of the brain showed atrophy again with chronic ischemic changes. No acute ischemic changes were noted. No enhancing process was noted.
The patient was loaded on Dilantin. After loading Dilantin, we checked the level of Dilantin and it was 12.2. EEG was mildly abnormal, in that it showed mild diffuse slowing. This was a nonspecific finding. No clear epileptiform waves were seen. Because of his complaints of vision abnormality, an orbital x-ray was obtained and no foreign body was seen.
Ophthalmology was also consulted. Exam finds that he has a macular degeneration, right greater than the left. He has a macular scar in the right eye, which is chronic and multiple soft drusen in the left eye, which appeared stable.
The patient is now stable for transfer to skilled nursing unit.
DISCHARGE STATUS: Family has chosen skilled nursing unit. He is being transferred today.
DISCHARGE MEDICATIONS: Levaquin daily x10, Fosamax 35 mg weekly, aspirin 81 mg daily, Citracal 950 mg t.i.d., Ditropan XL 10 mg daily, Hytrin 5 mg at bedtime, Sinemet 25/100 two tablets q.i.d., Dilantin 100 p.o. t.i.d., Tylenol on a p.r.n. basis, and artificial tears on a p.r.n. basis.
DISCHARGE INSTRUCTIONS: The patient will be followed by the doctor at the skilled nursing unit.
