CONSULTATION
This is a 22-year-old college senior who has had lightheadedness and dizzy spells going back a number of years, but apparently he never paid much attention to these spells until he had a seizure last year. He describes a sensation of vagueness which lasts a few minutes, and he had a similar feeling prior to the seizure. He experiences this sensation of vagueness quite frequently, 2 or 3 times a day, more often in the morning. He is not aware of any precipitating factors except that the feeling does have a tendency to increase with increased activities. He gets some flushing over the face and sweating over the palms, but he has never been told by others that he has any associated unusual movements of the hand or mouth to suggest automatisms. He has so far had only 1 definite witnessed episode of grand mal seizure. This was one day while he was spraying a lawn. He had consumed about 11 beers the night before and got 3 hours of sleep. He did have breakfast that morning and recalls getting wobbly and dizzy like he usually does, but then he lost consciousness and was witnessed to have jerking of the extremities. He did not have any tongue biting or incontinence. About a month later, when he had not been drinking, he had an episode in church when his eyes began to flutter, and shortly afterwards he left church. He believes that he was fully conscious during this entire episode, and he does not know if he had a seizure then. He has continued to have episodes of dizziness or lightheadedness and has been on Dilantin 100 mg orally t.i.d. since early July. In spite of being on Dilantin, he believes that there has been no significant change in the frequency of his dizzy spells except that he is now more aware of them, and when they occur, they bring back the memory of the seizure. On specific questioning, he recalls having had an episode while he was ushering at a light show. The blinking effect brought back memories of his seizure, and he felt dizzy. He also recalls feeling somewhat nauseated during these dizzy spells but denies having other symptoms of peculiar odor or taste during any of these episodes. He feels that at times there is perhaps some confusion after an episode, but he does not experience any headache. He denies any other symptoms suggestive of jamais vu or deja vu.
He was the product of a normal pregnancy and delivery and has had a normal childhood. He did well in school, and he denies any neurologic symptoms like head injury or episodes of vertigo, diplopia, frequent headaches, numbness, weakness, ataxia, etc.
Systemic review is otherwise negative.
Past history includes diagnosis of hypertension made at age 14 while he was in the eighth grade. There is no significant history of hypertension in the family other than his grandfather in old age. He does not recall having had any workup at that time, but he was placed on medication. He recently had a workup in New York last year, including urinary catecholamines. He does not remember ever having had an IVP.
FAMILY HISTORY
His first cousin has a seizure disorder and is still taking treatment. His grandfather had a stroke.
He consumes minimal to moderate amounts of alcohol, mostly on weekends. He is a nonsmoker.
EXAMINATION
He was found to be a pleasant young man in no obvious distress. Blood pressure was 160/100 in both arms. His pulse was 78 and regular. Pupils were equal at 4 mm each and normally reactive. The fundi were benign with no arterial narrowing or disk changes. There was no bruit over the neck or the scalp. No significant birthmarks were noted. Heart sounds were normal, and lungs were clear.
NEUROLOGICAL EXAMINATION
Mental status seems entirely normal. Cranial nerves 2-12 are intact. Sensory exam to light touch, pinprick, position, and vibration is completely normal and so are cortical sensations. Stereognosis is intact. Motor exam reveals normal tone and power. Deep tendon reflexes are bilaterally 2+. Plantars are downgoing. Finger-to-nose, heel-to-shin, and tandem walking were well performed. Romberg test is negative.
IMPRESSION
This patient has a normal neurological exam. It sounds as if he had had at least 1 episode of generalized seizure, and he continues to have episodes of dizziness or vagueness. He has already had a workup including a CT scan of the head with and without contrast, which was normal; an abnormal EEG with nonspecific slowing; and normal lab work including a normal GTT, CBC, SMAC, and urine catecholamines. At the present time, the main question is whether his dizzy spells are all unrelated or are the aura of a seizure or perhaps even manifest seizures. I tend to favor the latter possibility, that these are probably seizures themselves, as he is unable to give a precise history of his dizzy spells and does not know what is witnessed by others. These episodes sound stereotyped in nature, and he recalls the episode when blinking lights almost brought on a seizure, which would be similar to precipitation of his seizure with photic stimulation. It is possible that these episodes are all temporal lobe seizures and that it became a generalized seizure on that one occasion. If he continues to have definite seizures in spite of being on Dilantin, then he might be a candidate for a different anticonvulsant like Tegretol. Before making this change, I have rescheduled him for a sleep-deprived EEG with NP leads and will also obtain a Dilantin level. Depending on the results of those 2 studies, we will either plan on increasing his Dilantin dosage or changing him to Tegretol.
Thank you for having referred this pleasant, interesting young man, and if you have any further questions, please do no hesitate to give me a call.
FOOTNOTE
Line 21 (Page 2). Alternative: Disc.
Line 26 (Page 2). Exam was expanded to Examination in the heading.
Line 29 (Page 2). Are was changed to is for correct subject-verb agreement (Sensory exam ... is completely normal).
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