Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
Document the presenting concerns of the parents/guardian regarding the infantile spasms. This may include:
Witnessing episodes of sudden, brief, jerky body movements (flexion or extension) in clusters.
Developmental delays or regression (if present).
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at onset of infantile spasms.
Frequency and duration of spasm clusters.
Description of the spasms (flexor or extensor, body parts involved).
Developmental history (meeting milestones or regression).
Any recent illnesses or changes in behavior.
Past Medical History:
Prematurity or low birth weight (risk factors).
History of perinatal complications (hypoxic ischemic encephalopathy, meningitis).
Any other medical conditions (tuberous sclerosis, genetic syndromes).
Family history of infantile spasms or neurodevelopmental disorders (uncommon).
Family History:
Family history of neurodevelopmental disorders (uncommon).
社会史 (shè huì shǐ) Social History:
Not typically relevant for infantile spasms.
Physical Examination:
General examination: assess overall health and growth.
Neurological examination:
Assess for developmental milestones, muscle tone, and reflexes.
Look for signs of tuberous sclerosis (skin lesions, ash leaf spots).
Fundoscopic examination (may reveal retinal tubers).
Laboratory Tests:
Metabolic tests (blood, urine) – to rule out metabolic disorders.
Karyotyping – to identify chromosomal abnormalities.
Lumbar puncture (spinal tap) – to rule out infections or inflammatory conditions.
Imaging Studies:
Electroencephalogram (EEG): The gold standard for diagnosing infantile spasms. It will show characteristic “hypsarrhythmia” patterns during spasms.
Magnetic resonance imaging (MRI) of the brain: To identify potential underlying causes (tubersous sclerosis, malformations).
Diagnosis:
Infantile spasms.
Consider adding a descriptor for the specific type based on EEG findings (e.g., infantile spasms with hypsarrhythmia).
Specify the suspected underlying etiology if identified (e.g., infantile spasms associated with tuberous sclerosis).
Staging (optional):
Some classification systems stage infantile spasms based on the severity of EEG abnormalities and developmental delays.
Treatment Plan:
Early diagnosis and treatment are crucial to prevent developmental delays.
The goal of treatment is to stop the spasms and improve developmental outcomes.
Treatment options include:
ACTH (adrenocorticotropic hormone): The first-line medication for infantile spasms, often used with steroids.
Vigabatrin (antiepileptic drug).
Other medications may be added based on individual needs.
Ketogenic diet (may be considered in some cases).
Surgery (rarely used, for specific cases with identifiable lesions).
Prognosis:
Discuss the outlook based on the severity of infantile spasms, response to treatment, and presence of an underlying cause.
Early treatment can improve developmental outcomes.
However, some children may still experience developmental delays or intellectual disability.
Patient Education:
Importance of adhering to the treatment plan, including medication administration and dietary modifications (if applicable).
Early recognition and reporting of any adverse effects from medications.
The importance of developmental interventions (physical therapy, occupational therapy) to optimize development.
Support groups and resources for families with children with infantile spasms.
Next Follow-up:
Schedule for frequent follow-up appointments to monitor response to treatment, developmental progress, and potential side effects.
EEG monitoring will be repeated to assess the effectiveness of treatment in controlling the spasms.
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