JSK - Epilepsy

Patient: @NAME@ Bed: @ROOMBED@ Length of Stay: @RRHLOS@

Epilepsy Requesting Physician: *** Primary Neurologist: *** CC: *** Primary Diagnosis: *** HPI Summary: ***

Subjective, Overnight events and Hospital Course: *** - ***

Summary Exam: *** - ***

Assessment and Plan/Decision Making: Neurological:

***

@JSKME@

=====================

HPI Per Dr. *** on *** : "@NAME@ is a @AGE@ year-old @SEX@ with ***

Denies chest pain, abdominal pain, Nausea and vomiting."

Additional information is obtained from: EPIC records/ family member/caregiver

Onset of seizures:

Seizure Risk factors: -febrile seizures -family history of seizures -history of meningitis/ encephalitis -history of intracranial surgery -history of head trauma

Description of seizures/possible seizures: #1 -triggers -aura/warning; tongue biting, bowel/bladder incontinence -post-ictal confusion/ sleepiness/ combativeness -seizure frequency -last seizure

#2 -triggers -aura/warning; tongue biting, bowel/bladder incontinence -post-ictal confusion/ sleepiness/ combativeness -seizure frequency -last seizure

Other information regarding seizures: ictal speech, lateralized weakness

Current AEDs:

Previous AEDs and reason for stopping:

Implantable Devices or Surgeries: Previous neurologists: Previous EEGs: Previous imaging studies: History of Status Epilepticus: Driving Status: Mood: Educational/Employment Status: Current Birth control method:

=====================

COMPREHENSIVE PHYSICAL EXAM:

VITALS: Vitals with min/max:

Vital Last Value 24 Hour Range Temperature @FLOWINST(6::1)@ @FLOWSTAT(6:24::1)@ Pulse @FLOWINST(8::1)@ @FLOWSTAT(8:24::1)@ Respiratory @FLOWINST(9::1)@ @FLOWSTAT(9:24::1)@ Non-Invasive Blood Pressure @FLOWINST(5::1)@ @FLOWSTAT(5:24::1)@ Pulse Oximetry @FLOWINST(10::1)@ @FLOWSTAT(10:24::1)@ Arterial Blood Pressure @FLOWINST(301260::1)@ @FLOWSTAT(301260:24::1)@

GENERAL:  ***No apparent distress

EYES:  ***No ptosis, clear conjunctivae.  Pupil exam as in NEURO exam below

PSYCHIATRIC:
	Level of Sensorium — {conscience:123102}
	Orientation -- x {NUMBERS 0-4:108966}
NEUROLOGICAL:
	Language {jsklang:157530}
	Dysarthria {Dysarthria:155248}
	CN -- PERRLA, EOMI, Facial Droop ***
	Motor Strength -- 
	LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}
	LLE {NEURO RATING SCALE 5:119244}  RLE {NEURO RATING SCALE 5:119244}
	Motor Tone -- No cogwheel ridigity

MUSCULOSKELETAL:  Motor strength & tone as in NEURO exam above
	
CARDIOVASCULAR:
	Peripheral Pulses -- ***Dorsalis pedis & posterior tibialis pulses 2+ bilaterally
	Auscultation -- ***RRR.  Normal S1 S2.  No murmur
RESPIRATORY:
	Effort -- *** Normal
	Auscultation -- ***Breath sounds clear and symmetric

ABDOMEN: 
	Palpation -- ***No tenderness or masses.  No organomegaly
	Auscultation -- *** Normal bowel sounds

SKIN:  
	Inspection --  ***No masses or lesions by inspection
	Palpation --   ***No masses or lesions by palpation

====================== ROS: {jskros:157529}

======================

Historical Data reviewed:

PAST MEDICAL HISTORY: @MEDICALHX@ @SURGICALHX@

FAMILY HISTORY: @FAMHX@

SOCIAL HISTORY: @SOCH@

ALLERGIES: @ALLERGY@

====================== Data in the EMR was reviewed either in multidisciplinary rounds or separately. All neuroimaging in current admission and relevant prior imaging were personally reviewed.

Pertinent data as follows:

----------Medication Reivew---------- CURRENT MEDICATIONS

INFUSIONS @MEDSINFUSIONS@

SCHEDULED @MEDSSCHEDULED@

PRN @MEDSPRN@

Prior to Admission Meds @PTAMEDS@

----------Neuro---------- GSC @FLOWINST(2599::1)@ LOC @FLOW(5550000028)@ Eye @FLOWINST(2600::1)@ Verbal @FLOWINST(2602::1)@ CT: @LASTIMGIMP(img1001)@ CTA Head/Neck: @LASTIMGIMP(img1061)@ MRI: @LASTIMGIMP(img2006)@ MRA Head/Neck @LASTIMGIMP(img2127)@ @LASTIMGIMP(img2125)@

----------Cardiovascular---------- Cuff BP @FLOW(5::1)@ @FLOWSTAT(5:24::1)@ Art BP @FLOW(301260::1)@ @FLOWSTAT(301260:24::1)@ Coags @LABRCNT(pt:3,inr:3,aptt:3)@ Toponins @LABRCNT(TROPONINI:3)@ @LABRCNT(CKTOTAL,CKMB,CKMBINDEX)@ Thyroid @LABRCNT(TSH)@ Lipids @LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@ ECHO: @LASTPROC(ECHO101)@ EKG: @LASTPROC(ECG1)@

----------Renal---------- @IOBRIEF@ @LABRCNT(sodium:3,potassium:3,chloride:3,co2:3,glucose:3;aniongap:3,phos:3,mg:3)@ @LABRCNT(BUN:3,CREATININE:3)@ @LABRCNT(lacta:3)@

----------Pulmonary---------- Respiratory Rate @FLOW(9::1)@ @FLOWSTAT(9:24::1)@ SpO2 (@FLOW(250026::1)@) @FLOW(10::1)@ @FLOWSTAT(10:24::1)@

@LABRCNTIP(APH:3,APCO2:3,APO2:3,ASAT:3,AHCO3:3,FIO2:3)@

@VENTSETTINGS@ RT Assessments: Sputum @FLOW(302600)@, @FLOW(302610)@, @LASTIMG(img026:1)@

----------GI---------- LFTs @LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI)@ @LABRCNT(A1C)@

----------Infectious ----------

@FLOWSTAT(6:24)@ @LABRCNT(WBC:3,HGB:3,HCT:3,MCV:3,PLT:3)@ @LABRCNTIP(RESR:3,CRP:3,AST:3,GPT:3)@ @LABRCNTIP(creatinine:3,PCT:3,LACTA:3, VANCT:3)@ @LABRCNTIP(usp2g:3,uph:3,urob:3,uwbc:3,ubactr:3,unitr:3,LEUK:3,urbc:3,uwbc:3)@ Microbiology: @LASTLABX(SDES:4)@ @LASTLABX(CULT:4)@