Recurrent Seizure ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Seizure.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of developmental delay and seizure disorder who, according to his mother, was previously on Tegretol; although, it was stopped about a week ago because the patient was starting to get violent with it. Dr. Jane Doe recently switched them to Depakote, starting them on a dose of 125 mg daily. The patient got his first dose last night, and he had two brief general tonic-clonic seizures since about 3:00 in the morning. The patient has had some upper respiratory congestion and rhinorrhea but has been otherwise healthy, eating and drinking well.
PAST MEDICAL HISTORY: Autism, developmental delay, and seizure.
PAST SURGICAL HISTORY: Surgery for undescended testicle and unilateral orchiectomy.
ALLERGIES: PENICILLIN.
MEDICATIONS: The patient was just started on Depakote 125 mg daily.
REVIEW OF SYSTEMS: All other systems were reviewed with the mother and are negative. Review of systems not possible with the patient secondary to his history of autism and developmental delay.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is well nourished with stigmata of developmental delay and no acute distress.
VITAL SIGNS: Blood pressure 120/80, pulse 92, respirations 20, temperature 96.2, and O2 saturation 97% on room air, that is adequate and within normal limits.
HEENT: Head is atraumatic. Ears are somewhat low-set. The oropharynx is clear.
NECK: Supple. No JVD.
CHEST: Symmetrical chest wall rise, nontender.
HEART: Regular rate and rhythm. No murmur, rub or gallop.
LUNGS: Clear to auscultation. No rales, rhonchi or wheezes.
ABDOMEN: Soft and nontender. Positive bowel sounds.
EXTREMITIES: No cyanosis, clubbing or edema.
SKIN: Warm, dry, and intact.
NEUROLOGIC: The patient is awake and alert. He is very active. He is running around. He is interactive and moves all four extremities well.
ASSESSMENT: Recurrent seizure.
EMERGENCY DEPARTMENT COURSE: We discussed the case by telephone consultation with on-call neurologist, who suggested that the ideal eventual dose for this patient on Depakote would be about 30 mg/kg, and with the patient weighing about 40 kg, this would work down to 1200 mg a day or roughly 400 mg 3 times a day. She thought it would probably be best for this patient to slowly have his dose increased and to load the patient acutely with 500 mg of IV Depakote.
We discussed the case with the pharmacist and IV Depacon was available, so the patient had an IV line established and was given 0.5 mg of Ativan IV and was loaded with 500 mg of Depacon IV. Dr. John Doe had advised the mother to start to increase the dose already to 125 mg twice a day and then follow up with Dr. Jane Doe next week for probable dose increase.
Mom did have a lot of concerns about the patient being sedated, but we explained to her that this was at least part of the reason behind slowly increasing the patient’s oral dose, that he might be transiently tired but that he should probably get used to it.
DIAGNOSIS: Recurrent seizure.
DISPOSITION: Discharged.
DISCHARGE CONDITION: Stable.
