History and Physical — Patient 27

History

Present Illness: Patient #27 is a previously healthy 10 year old Caucasian male, transferred from another facility to Texas Children's Hospital emergency center for evaluation of sudden speech arrest. The incident occurred approximately four hours prior to evaluation while the child was in school; he raised his hand to answer a question, and when called upon, was not able to express his thoughts (though he was fully cognizant of his surroundings and situation). The episode lasted approximately 30 seconds and resolved spontaneously with full recovery of function. There was no loss of consciousness, abnormal movements, visual impairment, vertigo, numbness, or weakness.

In the emergency center, the child experienced a similar episode, lasting less than 30 seconds and characterized by inability to express his thoughts, left facial droop, left arm numbness, and left arm weakness. The symptoms again resolved completely.

Over the following 24 hours, the child experienced seven additional episodes of a similar character. Most episodes resolved spontaneously within 30-60 seconds following onset. The final episode, however, resulted in sustained deficits.

The patient suffered no intercurrent illnesses, fever, diarrhea, or head trauma.

Past Medical History: Two weeks prior to evaluation, the child had a mild upper respiratory infection with a sore throat. He also had a clinically confirmed (seen by a pediatrician) case of chicken pox one month ago. Within the past year, he has suffered occasional headaches. His birth and developmental history were normal. Immunizations were up to date.

Past Surgical History: None.

Allergies: No known drug allergies.

Medications: None.

Family History: There is no history of seizures, migraine headaches, or strokes. No female family member has had a miscarriage. His parents, 14 year old sister, and seven year old brother were in good health.

Social History: He attends fourth grade and receives A and B grades. There is no history of substance abuse and no recent travel exposures.

Physical Exam

General: Well developed, well-nourished boy appearing his stated age and in no acute distress.

Vital Signs: B.P. 135/85; pulse 80; temperature 98.9 F; respiration 18.

Chest: Clear to auscultation and percussion bilaterally with good respiratory excursion.

Cardiovascular: Regular rate and rhythm without rubs gallops or murmurs.

Abdomen: Soft, nontender, nondistended with intact bowel sounds; no hepatoslenomegaly.

Extremities: No cyanosis, clubbing, or edema.

Skin: There were signs of old, resolved eschars.

Neurological Examination

Mental Status: At the initial evaluation, the child's mental status was appropriate. His speech was normal with intact phonation, articulation, repetition, fluency, and comprehension.

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVisual acuity 20/20; visual fields were full; fundoscopic exam was WNL; pupils were 4 mm and reactive.
III / IV / VIExtraocular movement were full; there was no nystagmus or ptosis.
VSensation was intact in all three divisions bilaterally; masseter and temporalis strength was intact bilaterally.
VIISmile was symmetrical; intact orbicularis oris and oculi muscles.
VIIIHearing was intact to finger rub bilaterally.
IX / XPalate elevates in midline; gag intact bilaterally.
XISCM and trapezius strength intact bilaterally.
XIITongue midline without atrophy or fibrillations.

 

Motor: Tone was normal. Muscle bulk was normal. There was no cogwheel rigidity or tremor. Strength testing of both the upper and lower extremities were normal (5/5).

Reflexes: 2+/2+ for upper and lower extremities.

Sensation: Intact to all modalities throughout.

Cerebellar: Intact finger-nose-finger; normal rapid alternating movements; intact heel-shin.

Gait: Normal stance, stride length, arm swing and pivot.

After seven episodes of brief weakness and numbness over the initial 24 hour observation period, however, the child's physical examination changed. He now showed a mild left facial droop (central) with decreased left nasolabial fold, mild dysarthria, and numbness and weakness of the left arm and leg. Strength testing in the upper extremities at that time showed:

Strength

Right

Left

Upper Extremities

  
Deltoid54
Biceps54
Triceps54
Wrist Extensors53+
Wrist Flexors53
Finger Extensors53+
Finger Flexors53
Hand Intrinsics53

Lower Extremities

  
Iliopsoas54
Knee Extensors54
Knee Flexors54
Ankle Extensors54
Ankle Flexors54

 

Reflex

Right

Left

Biceps2+1+
Triceps2+1+
Brachioradialis 2+1+
Patellar2+1+
Ankle 2+1+

 

The patient also demonstrated some difficulty standing. When he walked, he tended to drag his left leg and lean to the left side.

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