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Initial Diagnostics

CT Malacic changes, CBC Hgb 138 Hct .42 WBC 8.5 N .72 L .24 M .04 PC 137. PT 12.2 INR 0.89 ALT 27.04 (10-40) BUN 4.48 Crea 99.01 (45-84) Na 137 (135-145) K 3.9 (3.6-5) Lipid Profile (results to follow). Initial Diagnostics. Initial Management. Phenytoin Loading dose 1gm

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Initial Diagnostics

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  1. CT Malacic changes, CBC Hgb 138 Hct .42 WBC 8.5 N .72 L .24 M .04 PC 137 PT 12.2 INR 0.89 ALT 27.04 (10-40) BUN 4.48 Crea 99.01 (45-84) Na 137 (135-145) K 3.9 (3.6-5) Lipid Profile (results to follow) Initial Diagnostics

  2. Initial Management • Phenytoin • Loading dose 1gm • Maintained at 1000 mg/cap TID • Admit to ACSU • Cardiac, CBG monitoring • O2 Support, seizure precauutions • Diazepam 5 mg IV • Ketorolac 30 mg IV then q8 prn for headache • Continue maintenance medications

  3. Day 1 -3 (Nov 7-9)

  4. Imaging Results • MRI: No aneurysm or any significant stenosis or vascular malformations seen • MRV: No evident cortical vein or dural sinus thrombosis

  5. Day 4 (Nov 10)

  6. Diagnostics • ECG: Atrial Fibrillation, RVR • TFT: • TSH 3.01 uIU/mL • FT3 2 pg/mL • FT4 0.83 ng.dL • EEG: abnormal EEG due to a focal theta slowing on the right temporo-parietal occipital region with wave epileptiform discharges on the right temporp-occipital region consistent wih a focal cerebral dyusfunction and a tendency toward localization-related seizures at the right temporo-occipital region

  7. Day 5-7 (Nov 11-13)

  8. Home Medications

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