History and Physical — Patient 87

History

Present Illness: A 23 year-old right handed Vietnamese man without significant past medical history who presents for evaluation of paroxysmal neurobehavioral attacks that started about six years ago. During this span, he describes three or four attack clusters during which several attacks occurred over a few days. Each attack seems to have similar presentations, beginning with a sensation of difficulty with swallowing. Subsequently, attacks may evolve to involuntary twitching of his right arm, followed by more diffuse twitching. Should the attack last less than a minute, he can usually maintain intact consciousness. However, should the attack become more prolonged, he will lose consciousness. Moreover, in midst of a couple of his attack clusters, he recalls losing his vision completely but temporarily, as the vision slowly returned over the subsequent days. Likewise, he also endorses concurrent memory deficits, dysarthria, as well as coordination difficulties that are again transient, lasting about one week after the end of the attack cluster. The patient was started on an anti-epileptic agent (name cannot be recalled by patient) that led to an apparent remission of his events for almost three years. This medication was eventually discontinued. However, several months later, the patient experienced another cluster of three breakthrough attacks, hence prompting his present evaluation. Notably, ever since this latest breakthrough cluster of attacks, his family has noticed progressive speech and hearing difficulties which have been persistent (rather than improving over time). Furthermore, his mood per his family appears to be more irritable and at times, depressed.

Review of Systems: He endorses weight loss due to loss of appetite. Otherwise, patient denies diarrhea, constipation, change in color of stool, chest pain, palpitations, night sweats, cough, SOB, wheezing, pleurisy, dysuria, urgency, frequency, urinary incontinence, hematuria, joint pains, muscle cramps, headaches, or any loss of muscle bulk.

Family History: There is no family history of seizures, and no febrile seizures in family. Father (76 years old) has diabetes. Mother (64 years old) also has diabetes.

Social History: He is currently a freshman in college and is not employed. He is single and lives at home with parents. No smoking, alcohol, nor illicit substance abuse. He is currently not driving.

Medications: None.

Allergies: No known drug allergies.

Past Medical History: Other than what is described in the HPI, he describes being healthy.

Past Surgical History: None.

Physical Exam

Vital Signs: Weight: 116 lbs. BP: 105/73, HR: 114.

General: Pleasant, thin appearing man of slightly shorter stature (5' 1", compared to his brother who is 5' 9").

HEENT: Normocephalic atraumatic. Sclera is anicteric. Nose and nasopharynx clear. Oropharynx clear with pink mucosa.

Neck: Supple. No palpable lymphadenopathy or thyromegally. No bruits heard.

Chest: Clear to auscultation. Normal cardiac rate, rhythm, normal heart sounds.

Abdomen: No organomegaly. Soft, non-tender, and non-distended.

Musculoskeletal: Full range of joint motion, without pain.

Extremities: No cyanosis, edema or skin lesions.

Neurological Examination

Mental Status: Awake and alert. He has difficulty with hearing, requiring some repetition of commands. He cannot repeat spoken sentences. When written down, he is able to read it aloud. Speech is slightly hesitant with apparent word finding difficulties. He seems easily confused, perhaps contributed by hearing deficits. Thought content appears tangential.

Cranial Nerves: PERRL, VFF, EOMI, no evidence of nystagmus, normal facial sensation and symmetry. Tongue is midline with normal symmetric palatal elevation. Sternocleidomastoid and trapezius strengths are intact bilaterally.

Motor: Normal muscle bulk, power and tone. Pronator drift is absent.

Sensation: Intact in all modalities throughout.

Coordination: F-N, H-S and RAM intact bilaterally.

Gait: Normal, including tandem. There is slight difficulty on reverse tandem.

Romberg: Absent.

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