MEDICAL REPORT
I. J, 43YEARS, MALE
Background information; A 43yr old man with a long- standing history of focal epilepsy- right mesial temporal lobe epilepsy, had surgery and was placed on neurotherapy (ethuxisimide),.
Diagnosis; Right medial temporal lobe epilepsy
Management plan;
·
Continue
I.V Phenytoin 100mg q8hrly x 1/7, then q12hrly x 1/7, then q24hr x 1/7 then
stop
·
Recommence
Epilim 500mg daily then 1g nocte
·
PO
Clonazepam 1mg nocte x 1/52
·
Do
FBC , LFTs
Date of Admission; 20/03/2023
Date of Discharge; 23/03/2023
Presentation and Neurology;
Brought in with cluster seizures.
Neurology: visual seizures with head movement towards the left.
O/E:
GCS – 15, Tone- difficulty in movement, power at least 4 in all limbs, reflexes symmetrical bilateral reflex planter response
Imaging and Differential Diagnosis;
MRI review shows profound gliotic scarification on the right temporal lobe with evidence of previous surgery.
UPDATE (21/03/2023)
He had breakthrough seizures and was admitted last night for emergency management of frequent seizures aborted with Midazolam and loaded with Phenytoin 1g. He was reviewed by neurologist who has recommended sodium valporate 500mg am and 1g nocte with chlonazapam added. EEG on hold to complete blood test for further review on neurology.
UPDATE (23/03/2023)
History as previously documented, GCS 15 on neuro-examination, nil focal neurological deficit
Discharge and Follow up
· Discharge home today
· Continue epilim 500mg am and 1g nocte
· Reduce clonazepam dosage to 0.5mg nocte for 3/7, then o.5 alternate days for 3/7 and then stop
· For optimization of epilim at next visit plus serum level check.
Kindly revert for further clarifications if need be.
Sincerely Yours,
Dr. Halima Ibrahim
For Team Wellington Clinics
----------electronically signed to prevent delay in transmission