Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Consultation
Description: Neurologic consultation was requested to evaluate her seizure medication and lethargy.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.
HISTORY OF PRESENT ILLNESS: The patient is well known to me. She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity. She also has a history of factor V Leiden deficiency. She was last seen at neurology clinic on 11/16/2007. At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue. She did well on 2 mL twice a day without any sedation. This past Friday, she had a 25-minute seizure reportedly. This consisted of eye deviation, unresponsiveness, and posturing. Diastat was used and which mom perceived was effective. Her Trileptal dose was increased to 3 mL b.i.d. yesterday.
According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal. She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers. According to mom, she had stopped vomiting since her hospitalization. Reportedly, she was given a medication in the emergency room. She still is lethargic, will not wake up spontaneously. When she does awaken however, she is appropriate, and interacts with them. She is able to eat well; however her overall p.o. intake has been diminished. She has also been less feisty as her usual sounds. She has been seizure free since her admission.
LABORATORY DATA: Pertinent labs obtained here showed the following: CRP is less than 0.3, CMP normal, and CBC within normal limits. CSF cultures so far is negative. Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64. There are no imaging studies in the computer. I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.
CURRENT MEDICATIONS: Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.
GENERAL: The patient was asleep, but easily aroused. There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures. She eventually started crying and became agitated. She made attempts to sit by bending her neck forward. Fully awake, she sucks her bottle eagerly.
HEENT: She was obviously visually impaired. Pupils were 3 mm, sluggishly reactive to light.
EXTREMITIES: Bilateral lower extremity spasticity was noted. There was increased flexor tone in the right upper extremity. IV was noted on the left hand.
ASSESSMENT: Seizure breakthrough due to intercurrent febrile illness. Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.
I concur with Dr. X's recommendations. I do not recommend any changes in Trileptal for now. I will be available while she remains hospitalized.
Keywords: consult - history and phy., lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal,