Admission Note for Seizures

DATE:

CHIEF COMPLAINT: Seizure

HISTORY OF PRESENT ILLNESS:

Onset-
Character-
Position- sittingsupinestanding
It lasted min
Loss of consciousness-
Seizure activity-
Witnessed-
Confused after the event- , Weakness after the event-
Speech difficulty-
Incontinent of urine/bowel-
Injury-

Sx before the episode:
Lightheadedness-
Racing heart-
CP-
Vision problems-
Nausea / Vomiting / Diarrhea-
Headache-
Abdominal pain-
Black/bloody stools-
Fever/chills-
SOB-
Missed recent doses of seizure meds-
Recent EtOH intake-
Sleep deprivation-
Recent illness-

Similar symptoms before-

ER Tx given-

PAST MEDICAL HISTORY:
Seizures Psychiatric disorder
MI CAD HTN DM Stroke GI bleed
Catheterization Echo
CA PUD PVD DVT COPD Asthma Gallstones

EGD Colonoscopy

PAST SURGICAL HISTORY:
CABG Cholecystectomy Hernia GSW Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH:
CAD<> 55 yo DM Stroke HTN CA

SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker: no
Illicit drugs- no cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarkable apart from above symptoms

PHYSICAL EXAM:
VITALS:
SpO2- Initial vitals-

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal

LABS:


Anti-seizure meds level:
CT head:
CXR:
EKG:

ASSESSMENT:
-Seizure due to
Epilepsy
TIA
CVA
Cardiac arrhythmia

PLAN:
-Telemetry
-Seizure precautions
-CPP x 2 q 8 hr
-EKG now and in AM
-Neuro consult
-2D Echo
-Carotid duplex
-UA
-Urine toxic screen
-Home meds
-Heparin 5000 U SQ BID

Signature:

Published: 02/01/2005
Updated: 03/08/2007



Related:

Treatment options for epilepsy - YouTube http://bit.ly/16aqZZr -- Jehuda Sepkuty, M.D., Medical Director of the Epilepsy Center and Clinical Neurophysiology Program at the Swedish Neuroscience Institute, talks about diagnosis of and treatment options for epilepsy.