Chief Complaint Case Study

575 Words3 Pages
Chief Complaint Seizure. History Patient is a 41-year-old right-hand white female who previously followed with me, but was lost to follow up in 2011. She was seeing me for combination of seizures and pseudoseizures. She was on Keppra 500 in the morning, 1000 at night. She has recently been admitted to the BHU. She had been noncompliant with her medication and was demonstrating some mood changes. She is unable to give any history. She cannot tell me when she stopped taking her Keppra. She was in the BHU had and event that was not felt to be an actual seizure, but was an attention getting event. She then, one to two days after discharge, had another seizure-like episode. She was at Lamprey and used the wall to slowly slide to the floor. Loss of consciousness was only 30 seconds with her eyes…show more content…
Cranial Nerves Ophthalmologic exam was benign. Visual fields full to palpation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula were midline. Normal auditory acuity. Normal shoulder shrug. Motor Was 5/5 all four extremities with normal tone. Sensory Was intact to primary modalities all four extremities. Cerebellar Revealed good finger-to-nose, heel-to-shin, rapid alternating motion. Gait Normal. Negative Romberg. DTRs 2+ throughout. Toes are downgoing. Impression This individual who may have a diagnosis of partial complex seizures or at least an abnormal EEG as evidenced by the fact that in the past I did put her on Keppra. The more recent events are very suggestive of pseudoseizures. She is not a Keppra failure for her August 4th event as she only had 500 mg IV in Portsmouth Hospital and was not given a prescription. Plan I am going to give her a prescription of Keppra XR 750 mg b.i.d. and I am going to get an EEG on her. I am going to attempt to get records from Lampre Health Care. She states that she may have last seen me in 2010 or 2011. I will attempt again to locate my records on

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