Date:
Patient:
Admitting Diagnosis: Status epilepticus (SE)
Seizure Type: (e.g., generalized tonic-clonic, focal motor)
Time of SE Onset:
HPI (History of Present Illness):
Summarize the details of the status epilepticus event, including:
Witness description of seizure activity (if available)
Duration of seizure activity before presentation
Presence of postictal state (confusion, lethargy)
Any potential triggers (e.g., medication withdrawal, metabolic derangement, infection)
Past medical history of epilepsy (known diagnosis, seizure type, medication regimen)
PMH (Past Medical History):
Relevant medical history including:
Underlying neurological conditions (e.g., brain tumors, stroke)
Metabolic or electrolyte abnormalities
History of substance abuse or withdrawal
Prior hospitalizations for SE
Physical Exam:
Vital signs (including temperature)
Neurological exam (level of consciousness, focal deficits)
Labs:
Electrolytes (sodium, potassium, calcium, magnesium)
Blood glucose
Complete blood count (CBC)
Renal function tests
Liver function tests
Toxicology screen (if indicated)
Lumbar puncture (if meningitis suspected)
Imaging:
Urgent head CT scan (to rule out structural abnormalities)
EEG (electroencephalogram) – to confirm ongoing seizure activity and characterize seizure type
Treatment:
Acute Management:
Medications to terminate seizure activity (e.g., benzodiazepines, intravenous anticonvulsants)
Supportive care (airway management, oxygen therapy, hemodynamic monitoring)
Identification and correction of underlying cause (e.g., electrolyte imbalance, infection)
Maintenance Therapy (once seizure activity has ceased):
Continuation of anticonvulsant medications (adjustments may be needed)
Diagnosis:
Status epilepticus (indicate specific seizure type if known)
Plan:
Continue monitoring for seizure activity (clinical and EEG)
Investigate and address the underlying cause of SE
Optimize anticonvulsant medication regimen
Consider EEG monitoring for prolonged or recurrent SE
Progress Notes:
Document daily progress including:
Response to treatment (cessation of seizure activity, improvement in mental status)
Changes in medication regimen
Identification and management of any complications (e.g., aspiration pneumonia)
Discharge Planning:
Medication regimen and refills for ongoing seizure control
Follow-up appointments with neurologist
Education on seizure triggers and management strategies
Consideration of epilepsy monitoring unit (EMU) admission for high-risk patients
Note: This is a template and should be adapted to the specific patient’s presentation, test results, and course of treatment