History:

Date & time: 02/15/23 9:00 am

Full Name: LK

DOB: 01/14/2006

Address: Jamaica, NY 

Age: 17 y/o

Sex: Male 

Race: Asian

Religion: Christian 

Source: Pt. himself

Transportation: EMS  

Reliability: Reliable 

Location: Flushing, NY 

Chief Complaint: “I had a seizure” x  1 day 

History of Present Illness:

     17 y/o male with no PMH, presents to Pediatric ED BIBEMS with mother after mother reports witnessing him seizing this morning. Pt has no previous h/o seizures. Pt. was getting ready for school and suddenly fell on the floor mother then saw the patient shaking and foaming at the mouth. She states the episode lasted about 2 minutes. Pt has no recollection of the events. Mom has h/o generalized tonic clonic seizure. Pt. denies fever, cough, nausea, vomiting, diarrhea, SOB, CP, dizziness, headache, urinary or bowel incontinence, tongue biting, numbness, tingling, weakness, h/o fall or head trauma, drug use, and sick contacts.

Past Medical History:

• Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

• No past surgical history 

Medications:

• Pt. states that he is not on any medications. 
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies. 

Family History:

• Mother – alive age 40 h/o generalized tonic clonic seizures
• Father – age 44 alive and well
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons

Social History:

• Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use.  
• Travel- Pt. denies any recent travel.
• Marital history- Pt states he is not married.
• Occupational history- pt states he is a student.
• Home situation- Lives with mother.
• Diet- Pt. states that his diet consists mainly of vegetables, protein, and rice. 
• Exercise- Pt. states he exercises for at least an hour every day. 
• Sexual Hx- Heterosexual. Denies h/o sexually transmitted diseases.
• Safety measures– Admits to seat belt use.

Review of Systems:

General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite. 

Skin, hair, nails – Denies changes in texture, excessive dryness, pigmentations, moles/rashes, pruritus, excessive sweating, or changes in hair distribution, 

Head – Denies headaches, vertigo, or head trauma, dizziness

Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat – Last dental exam February 2022. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Has regular bowel movements daily. Denies abdominal pain, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool. 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Nervous –Reports having a seizure and loss of consciousness. Denies migraines, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies anxiety, OCD or ever seeing a mental health professional. Pt. has h/o of depression. 

Physical: 

General: Thin male, neatly groomed, looks younger than her stated age of 17 years

Vital Signs: BP:                             R                                                       L

                  Seated                        113/79                                               116/74

                  R: 16/min, unlabored                                               P: 84 beats/min, regular

                  T: 97.6 degrees F (oral)                                         O2 Sat: 99% Room air

                  Height: 70-inches              Weight: 155 lbs                  BMI: 16.2

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars.

Hair: average quantity and distribution. 

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia. 

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  

Teeth – Good dentition / no obvious dental caries noted. 

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. 

Tongue – Pink; well papillated; no masses, lesions, or deviation. 

Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.

Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or lesions.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA, EOMs intact with no nystagmus 
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates, or neovascularization OU.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. non-tender to palpation throughout. 

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non tender to palpation in all four quadrants, with no guarding or rebound noted. Psoas, Obturator, Rovsing, and Murphy’s signs were negative. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Male Genetalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown. 

Motor/Cerebellar : Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Mental Status: A&O x 3, cooperative, thoughts & speech coherent. 

Cranial Nerves: II-XII intact

Sensory:Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated 

Meningeal Signs:No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E  B/L) No stasis changes or ulcerations noted.

Differential diagnosis: 

1. Brain hemorrhage- Pt. has a h/o of seizure and loss of consciousness. Would order a non-contrast CT scan to view the hemorrhage. Would also order CBC to monitor H and H and platelet count. Would also order PT and PTT to check bleeding time and assess any coagulopathies. After confirmation of hemorrhage would be admitted to ICU, lower BP below 140 mm Hg systolic and treat any coagulopathies that may be present.
2. Stroke- Pt ℅ unprovoked first time seizure with loss of consciousness. Would monitor airway, breathing and circulation via vitals. Would give the pt two large bore IVs, and put on a cardiac and pulse ox monitor. Would get POC glucose and put the patient on NPO. I would also get an EKG, CBC, CMP, PT, PTT, T/S, Troponin, Blood gas with lactic acid. Lastly I would get a noncontrast head CT or a CTA head and neck without contrast to determine if it is an ischemic or hemorrhagic stroke and decide treatment from there. 
3. Brain tumor- Pt. has h/o of seizure. Would order MRI with gadolinium to observe any lesions that may be present. If tumor is appreciated then schedule for biopsy and or resection of the tumor to reduce intracranial pressure. May do radiotherapy and chemotherapy as treatment along with steroids to reduce cerebral edema.
4. Electrolyte abnormalities- Even though pt denies any risk factors for evident electrolyte abnormalities such as vomiting or diarrhea. This still needs to be on the differential seeing that it is a common cause for unprovoked seizures. Would order CBC and BMP and monitor the patient. 
5. Substance Abuse: Even though the patient denies h/o substance use this still needs to be taken into consideration seeing that pt had what seems to be an unprovoked seizure and is 17 years of age. Would order UTOX, CBC, CMP, BAL, and monitor the patient for any acute changes in vitals or possibility of another seizure. 
6. Grand Mal Seizures- Pt. is complaining of recurring seizures, loss of consciousness, mother characterizes his episodes as a “shaking”, and has an unremarkable physical exam. Will order CBC to see WBC and Hematocrit and hemoglobin to see if infection or anemia could be the cause of seizures. Would order an MRI to view any abnormalities in the structures of the brain that might be causing the seizures. EEG placement in order to monitor brain waves and seizure activity.

Assessment: 17 y/o male with no PMH BIBEMS for suspected first time seizure not in any acute distress.

Plan:

CBC: to monitor H and H and to assess for possible infection. If normal, order a second one in 12 hours.

CT and cerebral arteriography: to determine if there is bleeding present in the brain and if so where it is.

EEG: in order to observe any epileptic episodes and brain wave changes that may or have occurred.

CMP: to monitor for electrolyte abnormalities and kidney functioning.

Utox and BAL: to rule out possible substance abuse. 

Furthermore: call neuro for consultation.