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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: TAN,NELLY Hospital #: 1709058 Age/Sex: 67/F Address: 1845 M Guazon St. Paco Manila Date of admission: April 12,2007 Admitting Diagnosis: Status Epilepticus Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V Residents in charge: Dr.de los Reyes/Indon/Estrada Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/Reyes

ABSTRACT
This is a case of a 67 year-old female who was admitted due to seizure episodes History of Present Illness Patient had 2 previous hx of severe seizure episodes (December 2006 & February 2007). Patient had no medications for seizure episodes. Patient was apparently well until… 1 hour PTA, patient had facial muscle twitching, stiffening of upper extremities. Patient became unresponsive to verbal stimuli. There was also upward rolling of the eyeballs, drooling of saliva , hence patient sought consult and was subsequently admitted. Past Medical History She was diagnosed to have DM type 2 maintained on insulin 20 u SQ at HS, Metformin 500mg tab TID, Gliclazide 800 mg tab TID, No HPN, No BA, No Hx of Cancer. (+) PTB- treated for 1 year with poor compliance INH, Rifampicin 3 tabs OD. Family History Patient denied heredofamilial disease. Personal and Social History Nonsmoker and non-alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Heumatology: no joint pains Physical Examination: Asleep, stretcher borne Vital Signs: BP: 110/80 HR: 60 RR: 20 Temp: 37.0oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, no distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, normal rate, PMI 5th ICS LMCL,regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, with full and equal pulses Assessment: Status Epilepticus

Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V
PLAN: For admission


				
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