EMERGENCY ROOM REPORT
HISTORY OF PRESENT ILLNESS
This child was born with cystic hydromas secondary to meningitis and has a permanent shunt in place. The child has had increasing frequency of seizures over the past few months and has been treated in the emergency room and hospitalized on several occasions for these. Today the patient requested that his mother pump his shunt and then began having left-sided seizures without vomiting or dyspnea. He was brought to the emergency room by ambulance and had resolution of his seizure activity following approximately 5 minutes of seizure activity. He had no incontinence at that time. The child had had no flu problems and had a recent Dilantin level of 16. He is currently on Dilantin Infatabs 50 mg, 3 in the morning and 2 in the evening.
LABORATORY DATA
Serum sodium 136, potassium 3.9, chloride 101, C02 28. Glucose 100, Dilantin level 16.6. The white blood count is 5900. Hemoglobin 14.5, hematocrit 41.2, MCV 87, MCH 30.2.
ASSESSMENT
1. Acute focal seizure secondary to underlying seizure disorder.
2. Ventricular-peritoneal shunt appears to be functioning adequately.
Note: CT scan performed 1 month ago documented this, and the shunt was pumped approximately 6 to 7 times. There was good residual filling of this shunt.
PLAN
The patient is to be started on phenobarbital 15 mg q.i.d., i.e., 2 mg/kg per day.
FOOTNOTE
Line 8. Alternative: Hygromas.
Lines 27-29. Enumerate the assessment for clarity.
Line 28. Alternative: Ventriculoperitoneal.
Line 32. Alternative: 6-7.
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