Neuro- LA 6

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School

DePaul University *

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Course

460

Subject

Medicine

Date

Oct 30, 2023

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docx

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Uploaded by hpurvins

Chief Complaint:  DF 37yr women who present to ER after having a seizure. Subjective:  Patient feels week and has a headache.  Head Pain 4/10  Symptoms started earlier today.  Has had seizures before, don’t happen often. Last one was 6 months ago.  Patient was found on the ground.  No family history of seizures  Patient has had headaches before but not migraines.  Patient felt an out of body experience before seizure.  No dizziness, N/V, or diarrhea  Does not take seizures meds.  No audio or visual changes  Did not hit head.  Has generalized weakness.  No loss of consciousness. Objective:  Temp 37  HR 72  RR 18

 BP 114/64  O2 100% on room air  All cranial nerves intact  Gait intact  Sensory and motor function intact  DTR- 2+ bilaterally in all  Patient has regular heart rate and rhythm.  Cap refill <2-3 sec  Positive peripheral pulses in all arteries.  Clear at all bases for lung field  PERRLA intact 1.)  In the past after a seizure have you had a headache?  Any brain scans done?  Do you drink?  Do you smoke?  Do you do illicit drug?  Do you have any triggers?  What medication are you on?  Have you changed your med routine? Any discontinuation or new meds?  Do you know how long it was?  Is your seizure absent or do you experience convulsion?  Any stress in your life?  Do you live alone or with someone?  Are your seizures affecting your mental wellbeing?  Are your seizures affecting your day-to-day life?  Are your seizures affecting your work?  Do your seizures affect your driving or ADLS? 2.)  EEG  CT  MRI

 Bloodwork 3.)  Tumors  Epilepsy  Trauma to the head  Metabolic changes  Interactions between drugs  Toxicity or poison levels  Fevers 4.)  Headache  Generalized weakness.  Post seizure state 5.)  pain management  fall precautions.  Seizures precautions 6.)  falls  brain injury  mental health  how patient has adapted to seizures.  carry medical identification. 7.) Based of the readings of subjective and objective data, this patient most likely had what time of seizures?  Atonic

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