Cheryl Greer Case Study Sample

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PROGRESS NOTE Cheryl Greer was seen in followup for history of seizures emanating form the left temporal region of her brain. She states that she has had no seizures since last seen by me about six weeks ago. She continues off of Keppra. She is now on Aptiom 600 mg twice daily for control of seizures. ROS: Psychiatric - History of anxiety. She continues on Lexapro 20 mg daily for this. She states that she feels this is helping with anxiety symptoms. She states she feels a little tired through the day with Aptiom, but states she can tolerate this. GI: She is not nauseated with Aptiom. SOCIAL HISTORY: She is working eight to 10 hour days. With having no further seizures, she is asking if she could return back to 12-hour shifts at work.…show more content…
She converses appropriately. She is in no acute distress. Blood pressure 140/90. Pulse 80 and regular. Weight 178 pounds. Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. She had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. The remainder of her cranial nerve examination was within normal limits. She continues to have good strength of her extremities. She had no dysmetria or dystaxia on finger to nose or heel to shin testing of either of her upper or lower extremities. She walks with a normal gait. IMPRESSION: History of seizures emanating from the left frontotemporal region of her brain. Her seizures have been under good control since last seen by me about six weeks

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