History and Physical — Patient 57


Chief Complaint: New onset seizures.

Present Illness: The patient is a 22 month old male, previously healthy until approximately 10 days prior to his hospitalization, when he was noted to be more irritable and fussy. His father reports that seven days prior to admission, the child began vomiting without relation to feedings, and began to walk "like he was drunk." Five days prior to his admission, the child began having seizure-like episodes. These "seizures" were described as intermittent shaking of arms and legs bilaterally. Initially these shaking spells only involved the child's arms, and were infrequent (once or twice a day). During the two days prior to admission, however, the shaking spells spread to include both arms and legs, and increased in frequency, occurring once every few minutes. These shaking spells are not associated with loss of consciousness, bowel/bladder incontinence, tongue biting, or post-ictal confusion. However, the child is very irritable immediately after an episode.

The patient generally appears more tremulous, exhibiting difficulty with holding objects. He drops things frequently and can no longer feed himself. His ability to walk has also deteriorated. He was walking essentially unassisted before the onset of symptoms, but his gait has worsened to the point where he has been completely unable to walk for four days.

Past Medical History: One ear infection during the first year of life. No surgical procedures.

Birth History: Normal spontaneous vaginal delivery at term. No maternal perinatal infections or obstetric complications were documented, and the child was discharged home after two days.

Developmental History: All developmental milestones were met at the appropriate ages.

Medications: Limited to p.r.n. acetaminophen.

Family History: The patient's mother and father are both healthy, in their 20's. There is no family history of seizures, gait disorders, or other neurologic disease.

Social History: The child lives at home with his mother and father. There is no reported day care, no recent contacts with sick children, no known exposure to chickenpox, and no recent travel out of the state or country. A dog and cat live in the house, but are reportedly healthy.

Review of Systems: There is increasing irritability, vomiting, tremors of hands bilaterally, and unsteady gait as described. There is no decrease in level of consciousness, fevers, recent viral infections, diarrhea. The child has mild occasional constipation. There are no known toxic ingestions or exposures.

Physical Exam

General: Child lying in father's arms quietly.

Vital Signs: Temperature 99.7 F; pulse 117/min, regular; blood pressure 110/76 mmHg; respirations 43/min, unlabored. Weight 12.3 kg (60 percentile); height 80 cm (60 percentile).

HEENT: Normocephalic, no evidence of trauma. Neck supple, no lymphadenopathy. Oropharynx and tympanic membranes clear.

Chest: Clear to auscultation bilaterally.

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

Abdomen: Soft, non-tender, and non-distended. Normal bowel sounds present. There is no hepatosplenomegaly and no palpable masses.

Extremities: No clubbing, cyanosis, or edema are present. No rashes or neurocutaneous lesions are noted on a detailed exam of the skin.

Neurological Examination

Mental Status: The child is awake and alert, fixes and follows the examiner's finger normally, is able to say a few words, follows simple commands.

Cranial Nerves: Pupils are equally round and reactive to light. Range of extraocular movements is intact, but spontaneous, jerky conjugate eye movements are noted in all directions, with a predilection for the horizontal plane. These movements occurred frequently throughout the exam and were noted at a later time to persist during sleep, although decreased somewhat in intensity. The face is symmetric, with normal facial expressions. The child responds to speech at normal volume; hearing was not quantitatively assessed. The palate and uvula elevate symmetrically. The tongue is midline without atrophy or fibrillations.

Sensation: Normal muscle bulk. There is generalized hypotonia. All four extremities are noted to move equally. Withdrawal to stimulation is observed in all four limbs. During the exam, the child had several brief episodes of whole-body jerking, paroxysmal and repetitive in nature, lasting a few seconds each, and without apparent alteration of consciousness.

Reflexes: Tendon reflexes are 2+ and symmetrical throughout. No clonus or reflex spread is noted. Plantar responses are flexor.

Cerebellar: As noted previously, there is generalized hypotonia. The child exhibits dysmetria when reaching for objects.

Gait: Unable to stand unassisted; when placed on his feet, the child falls to either side randomly.

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