Neurology case study

Dear Dr. (blank),

I am sending this patient to see you, who will be accompanied by her mother.  She is a 10-year-old Hispanic female who has been deaf since her birth and is mildly developmentally delayed.

I first saw the patient late last year for 2 “choking” episodes.  The first episode had occurred when the mother was awakened by hearing choking sounds from the child’s room.  When the parents entered her room, the patient was awake and alert and appeared to be in some respiratory distress.  Her tongue appeared to be curled downward onto the floor of the mouth, and when “straightened out” by the father, she began to breathe normally.  There does not appear to have been any associated eye blinking or other automatisms, and there were no upper or lower extremity tonic-clonic movements, nor was there an altered level of consciousness noted.  There did not appear to be any foreign body present, and there was no associated nausea or vomiting.

At that time, we felt that the patient was perhaps suffering from a focal dystonic process of the tongue or a localized lingual airway dysfunction.  An EEG was performed which was abnormal due to intermittent generalized frontal-dominant,
3 to 5 cycle-per-second spike and slow wave bursts and paroxysmal generalized theta wave bursts that occurred during drowsiness and waking state with no clear correlation with hyperventilation.  The rest of the record was well organized aside from these paroxysmal bursts.

Because of the history of premature birth requiring ventilator assistance for 4 months, evidence of mild generalized cerebral dysfunction, and history of petit mal epilepsy at age 5 years, it was not felt that the EEG was necessarily correlative with the patient’s symptoms, and she was not started on any antiseizure medications.

Two days ago, the patient’s mother called me to state that the patient had had another choking episode which resolved with manipulation of the tongue, but at that time it was associated possibly with altered level of consciousness.  The patient appeared dazed and quite drowsy throughout the event.  Again there was no clonic-tonic activity or other automatisms noted.  The patient is currently without complaints.

PAST MEDICAL HISTORY

The patient weighed less than 2 pounds at birth.  She goes to a special school.  She can read with some comprehension deficit.  She is independent in all of her ADLs.  She functions at an approximately third-grade level.  She had several episodes of staring spells at approximately 5 years of age, which were associated with a diminished level of responsivity and followed by crying episodes.  She had an EEG performed at that time and was on medication for approximately 2 months.  She has not had any more of these episodes.  Patient has occasional bifrontal headaches and recently started her menstrual period.

Because of the persistence of these episodes and the altered level of consciousness associated with the current event, in a child with an abnormal EEG and evidence of mild global brain damage, I started the patient on Dilantin 200 mg per day (approximately 4 mg/kg per day).  I have told the mother that this would be for 6 months’ trial period, presuming that these events occur approximately 1 to 2 times monthly.

I have requested that the patient see you, and I would appreciate any input you have into this situation.  I have myself not ever seen seizures presenting as choking episodes without generalized tonic or tonic-clonic activity.

If there are any other tests that you wish performed, please let us know and we will arrange them.

Thank you.

Sincerely,

Name.

FOOTNOTE

Line 13 (Page 1).  Re was not dictated but was supplied to demonstrate proper letter format.

Line 28 (Page 1).  Do not was changed to does not to correct grammar (There does not appear to have been ... blinking...)

Line 30 (Page 1).  Movement was changed to movements for proper
subject-verb agreement (There were ... no movements.)

Line 12 (Page 2).  Alternative:  ADLs (activities of daily living).

Line 27 (Page 2).  Alternative:  1-2.