Epilepsy Admission H&P

CC: ***
HPI
@M@ @NAME@ is a @AGE@ @SEX@ H/O *** presents with ***
Risk Factors
*** Patient has no h/o birth trauma, is a product of a normal pregnancy, labor and
delivery. There is no h/o early developmental delays, febrile seizures, head trauma or
cns infections. There is no family h/o epilepsy as well.
Semiology
***
Duration: ***
Frequency: ***
Triggers: ***
Diurnal Variation: ***
***
Duration: ***
Frequency: ***
Triggers: ***
Diurnal Variation: ***
Current Meds
@MEDSCURRENT2@
Prior Studies
EEG:***
MRI:***
EEG monitoring:***
Past Medical History
***
Surgical History
***
Social History
Patient lives at *** with ***. Patient ***
Family History
***
Family history is negative for neurological disease
Review of systems
As stated in HPI, otherwise: *** denies any nausea, vomiting, diarrhea, fever, chills.

Physical Exam
@VITALSM@
Gen: No Acute Distress; Resting Comfortably; A+Ox3, cooperative, not in respiratory
distress.
Pul: CTA bilaterally w/o wheezes, rhonchi,rales
Cardiac: RRR.
Abd: soft, non-distended, non-tender. BS normoactive.
Ext: Warm to touch. Pulses 2+ in all four extremities.
Neurological exam:
Mental Status: Alert and oriented to person, place, and time, no aphasia present. Fluent
speech. Good comprehension. Able to follow all commands appropriately. Able to read
sentences, repeat words, and name objects. 3/3 word recall.
Cranial Nerves: Visual fields intact. EOMI with no gaze deviation. No nystagmus
present. Denies any diplopia. PERRLA. Sensation intact in V1-V3 distributions.
Symmetric smile, eyebrow raise, good strength with eye closing. Palate elevates
symmetrically. No tongue deviation or uvula deviation. 5/5 strength with shoulder shrug
and head turn.
Motor:
No fasciculations or involuntary muscle movement noted. Normal tone and bulk
throughout.
Right: 5/5 finger abduction, 5/5 arm flexion, 5/5 arm extension, 5/5 shoulder abduction,
5/5 hip flexion, 5/5 leg extension 5/5 dorsiflexion, 5/5 plantarflexion
Left: 5/5 finger abduction ,5/5 arm flexion, 5/5 arm extension, 5/5 shoulder abduction, 5/5
hip flexion, 5/5 leg extension, 5/5 dorsiflexion, 5/5 plantarflexion
Reflexes:
Left: 2+ patellar, 2+ brachioradialis, 2+ biceps
Right: 2+ patellar, 2+ brachioradialis, 2+ biceps
Downgoing plantar reflexes bilaterally
Sensory: Intact to light touch, pinprick, temperature, and vibration. Symmetric bilaterally.
Coordination: Intact to finger to nose test, heel to shin, and finger following.
Gait: Normal gait with no ataxia. Normal heel-to-toe walking. Negative Romberg.
Labs, imaging and previous EEG recording reviewed.
Labs, imaging and previous EEG recording reviewed.
Assessment
@M@ @NAME@ is a @AGE@ @SEX@ H/O ***
Plan
- admit for video EEG monitoring to determine etiology of events
- will continue ***
- will plan to taper AEDs if no events
- Will obtain the level of ***, CBC and BMP.

- Will obtain neuropsych testing.

DVT ppx: lovenox
Diet:
Case was discussed with Dr. ***
Xuan Kang
PGY-2 Neurology
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