Clinical note · #43
Consultation
Patient: Andrew Collins
Age: 52
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Commercial PPO
Referring Provider: Dr. J. Martinez (Emergency Medicine)
Reason for Consultation: Neurology consultation for evaluation and management of new-onset seizure activity.
Chief Complaint: Episode of loss of consciousness with convulsions.
History of Present Illness (HPI):
The patient is a 52-year-old male referred for neurology consultation following a witnessed generalized tonic-clonic seizure that occurred one week prior. The event was associated with loss of consciousness, tonic stiffening, rhythmic jerking of the extremities, and postictal confusion lasting approximately 20 minutes.
He was evaluated in the emergency department, where initial laboratory studies were unremarkable. No prior history of seizures is reported. He denies recent head trauma, fever, infection, or substance abuse. The referring provider requested recommendations regarding further diagnostic workup and management.
Review of Systems (ROS):
- Neurologic: Seizure activity, postictal confusion
- Constitutional: Denies fever or weight loss
- Cardiovascular: Denies chest pain
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Hypertension
- PSH: None
- FH: No family history of seizure disorders
- SH: Denies alcohol or illicit drug use
Physical Examination:
- General: Alert, oriented, no acute distress
- Neurologic: Cranial nerves intact, no focal deficits
- Cardiovascular: Regular rate and rhythm
Diagnostic Data Reviewed / Ordered:
- Emergency department records reviewed
- MRI brain ordered
- EEG ordered
Assessment:
- New-onset seizure disorder
Plan:
- Initiate antiseizure medication
- Order MRI brain and EEG for further evaluation
- Discuss seizure precautions and driving restrictions
- Consultation report to be sent to referring provider