Seizure Disorder Discharge Summary Sample
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Seizure disorder.
2. History of traumatic brain injury.
3. History of bipolar disorder.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg by mouth daily.
2. Dilantin 200 mg by mouth twice a day.
3. Depakote 500 mg in the morning, 250 with dinner, and 500 at night.
4. Clozaril 325 mg by mouth at night.
5. Desmopressin 0.1 mg by mouth at night.
6. The patient is to resume all prior skin care and as-needed medications.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male admitted through the emergency department with seizure activity. It is unclear whether this patient actually has a history of a seizure disorder or not. Both he and his family deny history of seizure disorder; although, it is documented on the nursing home paperwork that he does have a seizure disorder, so it is not clear. In any event, the patient was admitted to the ICU as he did require intubation secondary to the seizure activity.
HOSPITAL COURSE:
1. Seizure disorder. Again, not clear if this is new onset or not. He had a lumbar puncture and an MRI, extensive evaluation, and was seen by Dr. John Doe of neurology, and it was felt that the likely indwelling source for the seizure is the history of traumatic brain injury. There were no structural deficits noted and no evidence of focal epileptiform activity on EEG. He was loaded with Dilantin, and he has had no further seizure activity since.
2. Respiratory failure. The patient was actually intubated more for airway protection and was presumed with respiratory failure secondary to the seizure activity and the sedation necessary to stop the seizure activity. He was easily extubated and had no further respiratory issues.
3. History of bipolar disorder. He continues on his Depakote and Clozaril.
4. Dysphagia. There was some concern about the possibility of aspiration. He had a swallow evaluation and modified barium swallow, which recommended mechanical soft diet with nectar-thick liquids, pureed meats, and no bread. He is doing well. At the time of discharge, he is awake, alert, and oriented. The patient denies any complaints and is tolerating the currently recommended diet without any difficulty. He is being discharged.
