History and Physical — Patient 53

History

Present Illness: A 73 year old, right-handed female was referred to the Neurology Service at the Methodist Hospital for evaluation of confusional episodes. These episodes, which started about two years ago, were described by the patient's husband and daughter. During an episode, she develops confusion, difficulty speaking and occasional language comprehension problems. She is sometimes noted to have drooling of saliva and to complain of double vision. She becomes disoriented to location and time. The patient has experienced these events on occasion while she was driving. Episodes are described as highly similar to each other, lasting about 30 minutes, and often followed by generalized headache but no nausea or vomiting. The patient prefers to go to sleep after these episodes. She herself is aware of the events and states that she knows what was happening. She does not describe any warning or prodromal symptoms. The frequency of confusional episodes varies from 2-3 per week to three per month. The patient and family deny bladder or bowel incontinence, and have not observed tonic-clonic motor activity during any of her episodes. The patient is a homemaker and is able to carry on all her usual activities without any hindrance. She and her family deny memory disturbances and personality changes. The patient does report a reduced level of energy. There has been no weight gain or loss, or depressed mood.

Prior evaluations have included testing for epilepsy and cerebrovascular disease. An MRI of the brain showed nonspecific white matter changes that were interpreted as consistent with age-related small vessel disease. A carotid doppler study was reported as normal. Several routine EEG studies were done, including one during a typical episode of symptoms. These studies were interpreted as essentially normal, at times showing intermittent slow activity in right and left temporal regions, a finding of uncertain diagnostic significance in elderly patients. Records from an emergency department visit in her home town during one of her typical events show essentially normal screening laboratory studies, including a blood sugar of 75 mg/dL, and an unremarkable examination.

Since she began to seek medical attention for her complaints, the patient has been treated empirically with a number of different approaches and medications. She was placed on prophylactic antiplatelet agents, most recently clopidogrel, without change in her symptoms. Various antiepileptic drugs (AEDs), including phenytoin (Dilantin), valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), tiagabine (Gabitril), gabapentin (Neurontin), and topiramate (Topamax) were tried over the previous year. Of these, Dilantin and Neurontin were rapidly discontinued due to adverse effects (skin rash, somnolence). The other medications, some of which have been tried in combination (dosages and schedules not available), were without effect. Prior to our evaluation, the patient was off all AEDs for about one month, with no change in frequency of her episodes. Due to her complaints of somnolence, modafinil (Provigil) was started at 100 mg in the morning for two weeks prior to our evaluation, without apparent benefit.

Past Medical History: Hypercholestremia, remote hysterectomy and oophorectomy. The patient has a long history of largely left-sided migraine headaches responsive to Midrin.

Medications: Clopidogrel 75 mg qd, atorvastatin 10 mg qd, modafinil 100 mg qd, and Premarin.

Family and Social History: The patient's mother died from pancreatic cancer, and her father died from prostate cancer. Some family members have migraine headaches. There is no family history of early strokes, diabetes mellitus or hypertension. There is no family history for seizures or epilepsy. The patient is a homemaker and a former florist. She has a high school education. She has three adult children, all healthy. She describes no toxic exposures, and does not smoke or drink alcohol.

Review of Systems: Essentially unremarkable. The patient denied chest complaints, palpitations, diaphoresis, syncope, or orthostatic symptoms.

Physical Exam

General: Well-dressed and well-nourished, pleasant and cooperative.

Vital Signs: The patient's temperature was 98 F (37 C). Her blood pressure was 142/88 mmHg, and pulse was regular, 64/min.

HEENT: No evidence of head trauma or malformation. No oropharyngeal lesions.

Neck: No carotid bruit or thyromegaly.

Chest: Normal cardiac exam with equal and symmetrical pulses; lungs clear to auscultation.

Abdomen: Normal, without organomegaly.

Extremities: Normal and symmetric pulses; no skin lesions or rashes; no edema.

Neurological Examination

Mental Status: Pleasant and cooperative. Folstein Mini-Mental Status Examination score 30 of 30. Bedside higher cortical function testing did not show speech disturbance, apraxia, alexia or agraphia, visuospatial abnormalities, or right-left confusion. There was good abstract reasoning and no disinhibition or perseveration.

Cranial Nerves: Cranial nerves II through XII were normal; in particular, no extraocular muscle weakness was evident.

Motor: Normal bulk and tone with strength 5/5 in proximal and distal muscles.

Reflexes: Tendon reflexes 2/4, without pathological reflexes or upper motor neuron signs.

Sensation: Intact modalities of primary sensation. Slightly decreased vibration in toes, deemed appropriate for age.

Cerebellar: Normal finger-nose and heel-shin tests, no dysdiadochokinesis.

Gait: Normal stance and arm swing. Able to bear weight on heels and toes. Able to tandem walk without difficulty.

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