Medication Sheet

Adrian Torreliza 31 yrs old,M

Date Started

1-23-11 CPZ 100-200mg BID q8

1-24-11 CPZ 100-200mg BID q8

Infirmary

11-16-10 Captopril 1tab 25 mg SL PRN BP=160/100

Record of ECT

12-8-10 BP=120/90 1st dose Complete seizure with

RR=20 spontaneous recovery
CR=80
T=36.4
12-9-10 BP=120/90 2nd dose Complete seizure with
RR=20 spontaneous recovery
CR=92
T=37.0
12-10-10 BP=110/80 3rd dose Complete seizure with
RR=20 spontaneous recovery
CR=99
T=35.4

Pre-ECT Examination

Gen. Survey: patient is alert,coherent,cooperative

BP=110/80 CR=99 RR=20 T=35.4

HEENT = normocephalic (-) NAD (-)TPC

Neck=supple (-) NVE (-)Lab

Chest= SCE-normal

Heart= AP NRRR (-)murmur

Abd= soft,flabby. NABS

Ext= no gross deformities EER

Skin= no active dermatose

Neurologic Exam

CN 1- can smell

CN 2- PERL

CN 3,4,6- EOM intact

CN 5- clench teeth

CN 7- no facial asymmetry

CN 8- can hear

CN 9,10 – can swallow, no slurry speech

CN 11- shrug shoulders

CN 12- tongue out @ midline

MOTOR= 5/5

SENSORY= 100/100

DTR= H2