Received Aug 12, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (ADACEL) | SANOFI PASTEUR | 1 | U8122AA | IM / LA |
Pt given vaccine according to protocol. Pt and mother went out of building to their car. Pt began seizing in passenger side of vehicle. Pt then lost consciousness for approximately 30-45 seconds. Two nurses went to assess pt and stated pt not breathing. Nurse performed sternal rub. Pt oriented, then 1st nurse went to pt and witnessed 2nd seizure. Nurse called 911 then fire and ambulance arrived. Took pt to hospital. BP 81/36 then 82/41. Per record review: CT Head - Impression: No CT evidence of acute intracranial hemorrhage or midline shift. Portable CXR - Impression: No active chest disease Glucose in ER - 85 CBC & Differential Abnormal. Notable for the following components: MCV 78.1 RDW 14.1 Platelets 416 Basophils 0.02 All other components WNL CMP Abnormal; notable for the following BUN 37 Creatinine 0.2 Urinalysis Reflex Culture Abnormal; Notable for the following components: Urine Protein Qual Random 1+ Bacteria Urine Rare Discharge VS B/P 121/50, Pulse 74, Temp 98.4, Resp 18, Oxygen Sat 95% Medications at time of Discharge DiazePAM 10 mg insert 10 mg into the rectum every 6 hours if needed for seizures up to 4 doses Discharge Disposition Routine MD Note: "Patient is a 13 y/o female presenting with a chief complaint of Seizures. Brought in by mom with chief complaint of seizure like activity. Otherwise healthy. No chronic medications. Was ate health department today receiving a tetanus update for school. She tolerated the immunization without difficulty. However on arrival to the car she became sleepy. Mother states she caught her out of the corner of her eye flapping her arms. Her eyse rolled back in her head and she was unresponsive. She did this twice. Each time lasted for about 1 minute. Mother states she has another child who has febrile seizures but reports that these were different because the patient was not postictal. Child denies alcohol, tobacco or illicit drugs. No recent falls or injuries. No recent illnesses. Takes occasional Benadryl for fluid on the ear. No over the counter medications.
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CT head w/o contrast; chest x-ray; blood glucose; CMP; CBC w/differential; Uninalysis. Differential Dx: CVA, TIA, meningitis, encephalitis, toxic metabolic encephalopathy, electrolyte disturbance, UTI, intoxication, seizure. Medications: Diazepam 10mg rectal kit sig: Insert 10mg into rectum Q6H prn seizures for up to 4 doses - per Dr. Follow-up with Neurology Consultants. Further instructions to pt: no baths, no swimming, no operation motor vehicles until cleared by neurology.