SHELTON, RENEE IPCase009 Dr. BLACK Admission: 09/18/YYYY DOB: 03/31/YYYYROOM: 322 ADMISSION DATE: 09

SHELTON, RENEE IPCase009 Dr. BLACK Admission: 09/18/YYYY DOB: 03/31/YYYYROOM: 322 ADMISSION DATE: 09/18/YYYY DISCHARGE DATE: 09/21/YYYY ADMISSION DIAGNOSIS: Syncopal episodes, rule out seizure disorder. DISCHARGE DIAGNOSIS: Same SUMMARY: The patient is a 17-year-old female in good health who on 09/15 while doing some canning at home suddenly collapsed onto the floor apparently losing consciousness. There was no seizure activity noted, and there was no postictal period. She was seen in the Emergency Room, evaluated and sent home. She had a similar episode on 09/16 and again on the day of admission. The episode on the day of admission occurred while she was walking with a friend, and she suddenly collapsed and fell backward. Her friend took her home, put her to bed, but then she had another episode and was brought to the Emergency Room. There was no documented seizure activity with any of the episodes. Past Medical History contained in the admission history and physical. Physical examamination on admission-blood pressure 138/88, pulse 88, respirations 20. Head Ears Eyes Nose Throat examaniation was normal. The pupils equal and reactive to light; extraocular movements intact. Sclera and conjunctiva clear. There was no nystagmus. Neck was supple with no thyromegaly. Lungs were clear. Heart had a regular rhythm with no murmur. Abdomen was soft, nontender, no masses or organomegaly. Breasts normal. Laboratory: A complete blood count on admission – the white count was 8,700 with 55 segmented cells, 34 lymphocytes, 10 monocytes and 1 eosinophil. Hemoglobin was 13. Urinalysis was essentially normal. SCG II on 09/20 was within normal limits. Calcium was 9.5, total protein 6.6, albumin 4, creatinine 0.9. An electrocardiogram was completely normal with no ectopic beats noted. Hospital Course: The patient was admitted to observe for further seizure activity and to attempt to initiate a work-up for possible seizure disorder. Because of inability to schedule an electroencephalogram, one was not performed during the hospitalization. During the period of time in the hospital, she had no evidence whatsoever of any syncope or seizure activity. Consultation was obtained with Dr. Bernard Knapp. He concurred with the evaluation as it was to be undertaken. The patient did develop some cold symptoms or rather a worsening of the cold symptoms she had on admission. Her examamination was unremarkable, and no specific therapy was given other than Tylenol. Her electroencephalogram was scheduled as an outpatient for 09/23. Since she has had no further seizure activity, she is discharged today to go home and essentially rest. She is to keep her activity to a minimum and return for the electroencephalogram which will be sleep-deprived, hyperventilated electroencephalogram. She was advised not to take any over-the-counter cold remedies prior to the electroencephalogram. Was also advised that she stop smoking. A note was given for physical education through 09/25.  SHELTON, RENEE IPCase009 Dr. BLACK Admission: 09/18/YYYY DOB: 03/31/YYYY ROOM: 322 09/18/YYYY CHIEF COMPLAINT: Passing out episode. HISTORY PRESENT ILLNESS: Miss Shelton is a 17 year-old female who has been in fairly good health without major problem with heart, lungs, kidney or diabetic problem. She had one episode on 09/15, Saturday about 2:30 while she was canning at home; suddenly she fell on the floor and collapsed. She didn’t say there was any eye movement or tonic-clonic movement, and witness did not notice those movements either. She didn’t have any pre- or post-episodic symptoms. She was in the Emergency Room and evaluated by the Emergency Room physician and was sent home. She had a similar episode on 09/16 between 8 and 9 which lasted about a couple of minutes, and at that time also she didn’t have any eye movements or tonic-clonic movement of hands and no mucus coming out from the mouth, but this time she felt there was some chest pain and after that she collapsed. 09/18 about 8:30 to 8:45 she was walking downtown with a friend and she suddenly collapsed and fell backward. Her friend carried her home and put her in bed, but shortly after that episode she had another episode of and was bought to the Emergency Room. Each time there was no documented witness that she had tonic-clonic movement or eye rolling backward or mucus coming out such as typical grand mal seizure. From description what this sounds like may be short period of petit mal seizure. Because of this recurrence, probably will have to admit to the hospital and watch for development and then might have to do electroencephalogram. Since we don’t have a neurologist here after stabilizing the patient probably have to send the patient to neurologist for evaluation. FAMILY HISTORY: She doesn’t know about father. Mother living, alive and well. She has three sisters and three brothers alive and well. SOCIAL HISTORY: Living with mother and stepfather. She is in school. Normally she is doing average work. Smokes half a pack a day and occasional drinking. REVIEW OF SYSTEMS: Unremarkable. PAST MEDICAL HISTORY: Allergies – no known allergies, No medications. Tonsillectomy. GENERAL: Well nourished, well developed, white female. No acute distress. EENT: Eyes: pupils equal and responding to light and accommodation, extraocular movements intact. NECK: Supple, no organomegaly or thyromegaly. HEART: Regular at 88 without murmur. LUNGS: Clear to auscultation and percussion. ABDOMEN: Soft and nontender. No organomegaly. Page 1 of 2 DD: 04/18/YYYY DT: 04/19/YYYY Physician Name GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 SHELTON, RENEE IPCase009 Dr. BLACK Admission: 09/18/YYYY DOB: 03/31/YYYY ROOM: 322 Page 2 continuation BREASTS: No masses, no nipple retraction. PELVIC: Not done. RECTAL: Not done. IMPRESSION: Probably petit mal seizure. PLAN: Will admit; watch for development and seizure precaution. Probably after we stabilize the patient, we may refer her to neurologist. We will also do an electroencephalogram.  DATE OF CONSULT: 09/16/YYYY CHIEF COMPLAINT: Rule out seizures with syncope. SOURCE: Ms. Shelton is a 17-year-old white female who presents with a history of being in reasonably good health until the Sunday prior to admission when she noted that while she was canning corn she had a “fainting spell.” She passed out, fell to the floor, and took several minutes to revive. She had another one of these spells on the subsequent Monday while she was on the phone. She apparently was sitting on a stool and again fell to the floor and awoke on the floor, and this was the next thing that she remembered. Apparently there was no tonoclonic activity and no prodrome for these episodes. The day of admission she was walking with a friend at approximately 8:30 PM along the side of a road when she “collapsed” with apparent loss of consciousness. This was for an undetermined length of time but surely less than several minutes and she was able, following this episode, to walk across the street. However, once arriving across the street, she collapsed again, falling to the ground and took several minutes to revive again. She was able to make it home with the help of her friend and had a third episode at home essentially in bed. These three episodes occurred over approximately a one hour period of time and as noted previously no tonoclonic activity was noted at any of the times. She has not been ill otherwise, and she has only noted that on one occasion she was slightly dizzy prior to passing out. PAST MEDICAL HISTORY: Unremarkable. PAST SURGICAL HISTORY: Reveals a tonsillectomy and adenoidectomy as a child. ALLERGIES: None known. IMMUNIZATIONS: Up-to-date. MEDICATIONS: At present, includes birth control pills which she has been taking for approximately six months that are dispensed through Family Planning, in Hornell. She stopped taking them on a routine basis on the Sunday prior to her difficulties. This is as scheduled. Her periods otherwise have been normal without problem. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lives in Almond with her mother, stepfather and siblings. She attends Alfred-Almond Central School where she is a senior; she reports no particular problems either at home or in school. On physical exam we find a well-developed, slightly overweight white female in no acute distress. VITALS: Temperature 98.6. Heart rate 100. Respiratory rate 18. Blood pressure 100/70 sitting and 120/70 lying down. SKIN: Clear. Head Ears Eyes Nose Throat: Essentially unremarkable. Pupils equal, round and reactive to light and accommodation. Extra-ocular muscles are intact. Discs are flat with normal vessels. Nose and throat exam are normal. NECK: Supple. Without masses. CHEST: Clear to auscultation and percussion. CARDIO-VASCULAR: Normal heart sounds without murmur. It should be noted that there’s a normal rhythm for at least two minutes of auscultation. Good peripheral pulses are noted. ABDOMEN: Benign, without hepatosplenomegaly, no masses or tenderness elicited. Genitourinary: Normal female Tanner stage five external. EXTREMITIES: Clear without hip clicks. NEUROLOGIC: Alert, active, cooperative, oriented x three white female in no acute distress. Cranial nerves two through twelve are intact. Deep tendon reflexes are +2 and symmetrical bilaterally. No clonus. Toes are downgoing bilaterally. Cerebellar examination, muscle tone and strength are all normal. Page 1 of 2 DD: 09/20/YYYY DT: 09/23/YYYY Physician Name GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 SHELTON, RENEE IPCase009 Dr. BLACK Admission: 09/18/YYYY DOB: 03/31/YYYY ROOM: 322 Page 2 continuation INITIAL IMPRESSION: Ms. Shelton is a 17-year-old white female who presents with what appears to be five episodes of “passing out.” These syncopal episodes occurred at many different times, including while canning corn, while talking on the phone, twice while walking and once while in bed but not asleep. She has a normal physical examin and it is difficult to elicit any organic etiology at this status of the investigation at present. Syncopal episodes in children and young adults have multiple etiologies. Surely not the least of these is petit mal or absence seizures. The differential diagnosis however or problems can be quite lengthy. This would include psychomotor seizures, syncopal attacks such as with prolonged QT interval, hysteria or hysterical hyperventilation syndromes in addition to a number of metabolic conditions with regard to hypoglycemia, hypoparathyroidism, etc. Obviously the workup for this young lady could be quite lengthy, and one should resist the temptation to shotgun her initially. I feel that the most appropriate examination to do at the present time would be an electroencephalogram to rule out the possibility of some type of seizure disorder. Following obtaining this examination, and should it be normal, then, perhaps, looking more into the cardiovascular area with Holter monitoring and/or stress testing might be appropriate. One thought does come to mind is in regard to electroencephalogram; she could be sleep-deprived and then hyperventilated during that procedure to precipitate any underlying seizure difficulty. Following the above mentioned examinations, further examinations surely could be carried out but these would need to be following these mentioned tests and not coincident with them. At present I would recommend withholding medication as we don’t know exactly what we would be treating with the medication. I think that reassurance can be given to the young lady as well as to her parents as to the seriousness, or actually non-seriousness, of her condition in that she has what would be considered completely normal physical findings. Thank you for consulting me on this most interesting young lady. I’ll continue to follow along with you as needed.  SHELTON, RENEE IPCase009 9457 Park St. 09/18/YYYY Almond 09/18/YYYY New York 14804 (607)000-7176 F 03/31/YYYY Satisfactory AMA Home DOA Inpatient Admission Code Blue Transfer to: Died Instruction Sheet Given No Yes EXPLAIN: Penicillin No Yes Birth control pills 138/88 88 20 99 Dizziness Patient states she was walking with a friend tonight when she suddenly collapsed. Her friend carried her home and she was put to bed. She then collapsed again. The patient states she remembers bits and parts of this experience. Denies any use of drugs or alcohol. Patient complains of some discomfort in her left arm and right leg. No redness, lacerations, abrasions, or swelling noted. Possible fainting spell. Syncopal episode, rule out seizure disorder. Reviewed and Approved: Cindy Stevens, RN ATP-B-S:02:1001261385: Cindy Stevens, RN (Signed: 09/18/YYYY 10:30:40 PM EST) Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 Shelton, Renee IPCase009 Emergency Room Dr. Ben King 09/18/YYYY 03/31/YYYY !”# Symptoms: 17-year-old white female who was seen 3 days with a sudden syncopal episode and tonight while walking with a friend suddenly collapsed. She was somewhat groggy for awhile, got up and walked and was light-headed and collapsed again and reportedly was unconscious and then got up and passed out twice more while lying down at home. There was another episode where she was talking on the telephone when she got chest pain across her chest and fell off the chair. Objective: Patient is alert and awake at this time, fundi are benign, chest clear, heart regular rate and rhythm, reflexes normal, no carotid bruits. Assessment: Syncopal episode, rule out seizure disorder. Plan: Patient will be admitted. PLEASE help with these:DRG assignmentPDx assignmentSecondary diagnosesProcedure codesidont need help with include noninvase procedures (foley catheters, radiology, etc.)All responses have to be correct in order. Health Science Science Nursing BIO 303 Share QuestionEmailCopy link Comments (0)

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