Seizures Case Study

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CHIEF COMPLAINT
Seizures.

SUBJECTIVE
Mr. Crittenden presents at clinic today to follow up on seizure management. He states I do not have his full records here since it since looks like he was an RV and admitted here on 01/12/2017. 1. He states that he had a seizure history. He states that he had seizures starting at age 2. He states he currently has been seizure free for 1.5 years. Prior to that he had a episode about eight months prior to that where he had two seizures back-to-back. He states that when he was at the Stillwater facility one of the doctors had stopped his Dilantin, which he has been on Dilantin 100 mg capsules four capsules daily which he had been on for years. Then another physician restarted the Dilantin and had a blood level done on 10/12/2016, which showed that it was low level at 6.6. He states he had just been restarted on the Dilantin when that level was drawn. He denies any problems or issues at this time. He would like to be placed on KOP. 2. I did note his blood pressure to be slightly elevated today. He states that has happened once in the past. He has never been treated for that and I do note that his admission blood pressure was within normal limits. He denies any chest pain, shortness of breath. He denies any family cardiac history.

OBJECTIVE …show more content…
Pleasant, alert, oriented male who appears in no acute distress. Gait and balance appear within normal limits. Pupils are equal and react to light. Conjunctiva sclerae are clear. Peripheral vision within normal limits. Cranial nerves 2-12 essentially intact. Strength is equal in all extremities. Sensation intact. DTRs are 2+ and symmetrical. Romberg test is negative. Chest is clear to auscultation. Heart rate and rhythm regular. No peripheral edema

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