DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Asperger syndrome.
2. Bipolar disorder.
3. Syncopal episode, now resolved.
CONSULTANTS:
1. Jane Doe, MD, Psychiatry
2. John Doe, MD, Neurology
PROCEDURES PERFORMED:
1. Electroencephalogram.
2. MRI of the head.
3. Echocardiogram of the heart.
BRIEF HISTORY OF PRESENT ILLNESS: This is the second admission in the last several days for this (XX)-year-old Hispanic male with a history of Asperger syndrome and some behavioral problems, including bipolar disorder, for which he has been on psychotropic medications. He was recently hospitalized with lethargy and elevated valproic acid level, in the 250 range. During his hospital stay at that time, his valproic level had dropped to 82, he was tolerating feeds, and therefore was discharged home. When he got home later that evening, he received his usual dose of 600 mg of Seroquel in the evening but was later found by his father to be lethargic, diaphoretic, and complaining of excessive tiredness. Therefore, the patient was brought back into the emergency department.
The patient was tachycardic on arrival to the ED, but his vital signs were otherwise stable. He was given 1 liter of normal saline bolus at the time, and an EKG was done, which revealed a normal sinus rhythm with a QTc of 396 milliseconds and QRS duration was 84 milliseconds.
LABORATORY DATA: Initial laboratory data showed a white count of 3200, which is up from his prior admission, hemoglobin of 12.2, hematocrit of 36.2, and platelets of 194,000 with 36 segs, 6 bands, 35 lymphocytes, 16 monocytes, and 4 lymphocytes. Basic metabolic panel was unremarkable. CPK was 110. The valproic level was 26. Urine toxicology screen was positive for tricyclics, but this is not unexpected since the patient is on Seroquel.
HOSPITAL COURSE: The patient was admitted to the pediatric progressive care unit for neurologic and cardiac monitoring. An echocardiogram done of the heart revealed normal cardiac anatomy and function with trace tricuspid, pulmonary, and mitral regurgitation. Neurology was consulted, and an EEG and MRI of the brain were done, with the EEG being normal for age and MRI negative for any pathology. Further lab tests were also done, which included an ESR level. TSH was normal. ANA was negative and anti-RNP antibody was also negative. B12 level was slightly elevated at 1268.
IV fluids were given to the patient on his arrival to the floor. The patient continued to do well and was later able to be transferred to a regular medical bed on the peds floor. Psychiatry was consulted, and adjustments were made to his psychotropic medication. The Depakote was initially held at the time of admission but later restarted. The Seroquel evening dose was decreased from 600 mg to 300 mg, per Psychiatry recommendations. Trileptal was also discontinued during his hospital stay.
The patient continued to do well without further complaints of weakness, dizziness, near syncopal episodes or lethargy. The patient tolerated p.o. well and ambulated without difficulty.
DISCHARGE MEDICATIONS: The patient is to be discharged home on the following medications:
1. Seroquel 25 mg p.o. q.a.m., Seroquel 50 mg p.o. q.p.m. at 1700 hours, Seroquel 300 mg p.o. nightly.
2. Depakote ER 500 mg SR tablets p.o. daily.
3. Prozac 10 mg p.o. daily.
4. Clonidine 0.1 mg p.o. q.a.m., clonidine 0.05 mg p.o. daily at 1300 hours.
DISCHARGE INSTRUCTIONS: The patient is to follow up with the psychiatrist in one week.
