CASE STUDY #1
JULY 13, 2001
EMERGENCY ROOM CONTACT
Patient is a 42 y.o. male presenting to ER, via EMS, experiencing seizure activity since approximately 0850. EMS called to the scene at 0915 and patient presents to ER at 0925.
According to patient’s wife, patient was seen in ER on July 1st for seizure activity. Patient’s medical history was otherwise normal up to this point. Patient is married and has two children. Patent does not smoke or drink alcohol. Patient is a truck driver that works the night shift. On July 1st, patient was admitted for observation following ER presentation. A CT was ordered and revealed lesions on the left brain about 2-3 cm’s long. Patient was scheduled to leave for Texas tomorrow for further evaluation. Patient’s wife describes this recent event as “mild ticks to the left arm with short intermittent breaks in seizure activity.”
Patient’s vital signs were 136/78 with a pulse of 112. Breath sounds are clear and heart sounds are normal. DNV’s reveal diminished grip in left arm. Wife state’s this is normal since his previous seizure on July 1st. Patient’s skin pink, warm and mildly diaphoretic. Patient’s LOC is diminished. Patient can respond briefly to verbal commands. Patient is experiencing mild focal motor seizure activity to the left arm and head/neck.
Patient’s lab data is normal with the exception of his Tegretol level. Patient’s Tegretol is currently 4.2 vs. a normal range of 8 – 12. Patient’s liver enzymes were currently normal which is improved from his July 1st levels that were low.
Patient is currently taking: Diazepam, 5mg TID for the treatment of seizures. Famotidine 20mg BID for a peptic ulcer. Tegretol 200mg BID for treatment of seizures. Vidodin, 2 – 3 q4-6hr PRN for pain relief.
PA ordered establishment of IV with a saline lock, O2 at 4 lpm by NC and 3-lead monitoring. Ativan 0.5ml given IVP to relieve seizure.
EMS PLAN OF ACTION
Protect the patient from harm and do...
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