Morning round

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  • Publicado : 16 de noviembre de 2010
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Morning rounds
* 17 y/o with new onset seizure. Sz, observed by brother, lasted ~12 min with post-ictal period of 6 min. Patient was evaluated at HGM, no laboratory orradiologic tests were performed, no meds prescribed, patient was D/C home.
* At 6 am next morning, pt had 2nd seizure lasting ~10min with a 6 min post-ictal period. Following both seizures, patient wasnot aware of the incident, no encopresis, incontinence or biting of his tongue. No associated fevers, N/V, abdominal pain, diarrhea, no aura or HA prior to seizure.
* PMH:
* HAapproximately every 10 days since childhood, resolved with Advil/Tylenol, never formally evaluated.
* Gastritis x 3 yrs.
* Asthma at 10 yrs old-resolved.
* Several episodes of inabilityto move his extremities when awakening from sleep (hypnopompic paralysis) during childhood.
* FHx:
* Non-contributory, parents live Guerrero.
* Two brothers, five sisters, allhealthy.
PSHx: None
Developmental Hx: Completed 6th grade.
Immunizations: Unsure, last vaccination at age 13 yrs.
* Hospitalizations: Fx leftclavicle 6 yo, Fx right ankle 8 yo, no complications.
* Social Hx: Moved from Guerrero 2 yrs ago. Lives with brother (19), and two friends in an apt. No tobacco, alcohol, drug use. Denies anysexual activity ever. No sick contacts. No travel outside or inside the country since moving here. No food from outside of country. Works as a waitress at a Mexican restaurant.
* Meds: None.Takes herbal supplement “Sukkol” (Glutamic acid, Lecithin) qod x 1 month for memory and energy and Chamomile tea for gastritis.
* Allergies: NKA
Physical Exam
* Ht: 147.3cm Wt: 52kg
* T:37.6 BP: 104/59 P: 86 R: 24
* HEENT: PERRL(pupils equal, round, reactive to light), EOMI Extra Ocular Muscles Intact
* Neck: Supple, Brudzinski-Neg, no nuchal rigidity no LAD
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