PROBLEMS:
1. Medically refractory focal epilepsy.
2. History of left frontal astrocytoma, status post chemotherapy and radiation.
3. Arthritis of the left and right shoulder.
MEDICATIONS: Keppra 500 mg 3 times daily, lisinopril 20 mg daily, Zonegran 300 mg in the evening daily.
SUBJECTIVE: The patient is a (XX)-year-old, right-handed man with a history of refractory seizures. He has complex partial seizures that are preceded by a wave or indescribable sensation that lasts a couple of seconds followed by speech difficulty, metallic taste, mouth watering and impairment in awareness. During his last visit, we started him on Zonegran 300 mg per day. Initially, the patient did not have any seizures until he was switched to the generic version, zonisamide. On the generic, the patient had five seizures over 2 months. He was switched back to Zonegran about 2 weeks ago. He has not had any further seizures for about 4 weeks now. He denies any side effects from the Zonegran.
NEUROLOGIC EXAMINATION: Decreased rapid alternating movements using his right hand, otherwise normal.
PRIOR MEDICATIONS: Tegretol and Dilantin.
DIAGNOSTIC STUDIES: An MRI of his brain revealed an extensive abnormality involving the left frontal operculum into the insula and temporal pole with a porencephalic cyst in the inferior frontal region. Video EEG monitoring revealed frequent left frontotemporal spikes and sharp waves in sleep and two complex partial seizures with no initial change for 30-40 seconds followed by a late left hemisphere discharge, maximum in the left mid temporal region. His electrolytes, including his liver function tests, were normal. His complete blood count was also essentially normal with the exception of a borderline low platelet count of 144.
IMPRESSION AND PLAN: We have recommended that he continue on a combination of the Keppra and Zonegran. He has not had any seizures on the current dose of Zonegran. It is medically necessary that he only take brand name antiseizure medications to control his epilepsy. If he has any further seizures, he knows to call our office. We will see him in followup in 6 months. He is scheduled to undergo a followup MRI of his brain.
Epilepsy Sample Report #2
PROBLEMS:
1. Symptomatic focal epilepsy.
2. Traumatic brain injury.
MEDICATIONS: Keppra 1000 mg in the morning and 1500 mg in the evening daily, lisinopril 10 mg daily, Risperdal 3 mg twice daily, Flomax 0.4 mg daily.
SUBJECTIVE: The patient has not had any further seizures since his last visit. His last generalized tonic-clonic seizure was on MM/DD/YYYY. At that time, he was found to have pneumonia and was on Zithromax. There was some question about whether he was having complex partial seizures, about once per month. He has not had any further episodes of staring or unresponsiveness. He denies any new neurologic symptoms. He has been having some delusions. This has improved.
NEUROLOGIC EXAMINATION: Unchanged.
DIAGNOSTIC STUDIES: An EEG done today showed loss of faster frequencies and slowing over the right hemisphere, but no epileptiform abnormalities. A CT of his head showed a fairly large right extra-axial fluid collection with a craniectomy over the right frontal temporal region. Keppra level on MM/DD/YYYY was less than 5. On MM/DD/YYYY, it was 26.
PLAN: We are pleased that the patient is doing well. He will continue taking the current dose of Keppra. He will also take calcium and vitamin D supplements to prevent any associated bone loss. He is undergoing physical therapy twice a week and is able to walk with assistance. His behavior has improved with more companion time. We will see him in followup in 6 months if he continues to do well.
