Neurology Case Study

Had a repeat MRI of the head.  She had a lesion seen in the right frontal lobe on previous CT and MRI scanning.  This lesion has not changed at all over time.  I have reviewed this with our neuroradiologist here, and it seems somewhat unlikely that this is a low-grade glioma.  We have really pursued quite a great deal in the way of workup for this very unfortunate woman’s dementia.  One thing that we had not done was a lumbar puncture, and I think that this is probably quite reasonable given the fact that we have not found a treatable cause for her memory loss and are really, more or less, presuming that the underlying disease is Alzheimer disease.

I would suggest that a lumbar puncture be done and that spinal fluid be sent for VDRL, AFB stain and culture, fungal stain and culture, cryptococcal antigen, bacterial culture, glucose, protein, and cell count.

Neurology Case Study

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).

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.

Neurology case study

CONSULTATION

CHIEF COMPLAINT

Left hemiparesis.

PERTINENT HISTORY

Apparently, this patient has an extensive past history of alcohol abuse but claims that he abruptly discontinued alcohol intake approximately 12 years ago.  He had the acute onset of left hemiparesis.  Currently this problem has apparently been quite responsive to rehabilitation, with the patient’s primary physical residual being upper extremity weakness.  Patient reports that he is within normal limits in terms of his gait ability at the present time.

The patient’s neurorehabilitation program has apparently been successful as planned.  A psychological consult was requested in order to assist in discharge planning issues — particularly in identifying the patient’s ability to return to his employer.

OBSERVATIONS AND TEST DATA

The patient was interviewed and examined on an exercise mat within the physical therapy area.  The environment was relatively distracting for the patient.  He was in mild discomfort, claiming that his “back hurt.”  Otherwise, the patient appeared to be alert and was able to articulate his recent and past history for me in a fairly coherent fashion.

The patient’s speech is marked by some slurring as he speaks more quickly.  There is also a flat quality (monotone quality) to his speech.  Content of his speech is appropriate.  No evidence of tangential or circumlocutory speech was displayed.

The patient was able to count backwards from 20, albeit his performance was very slow.  The patient was able to recite the alphabet without difficulty — again, slowly.  His recollection for long-term history and events was unimpaired.  Short-term memory was impaired.  Patient was able to recall 1 object of 3 in 3 minutes.

The patient’s recall of the past 5 presidents was excellent.  His orientation was x4.

The patient’s insight and judgment appear to be poor.  He offered little insight into the need for careful review of his mental status prior to returning to work, claiming that since he had a chauffeur, there would be no difficulty.  He also claimed that since he was in management, there would be no difficulty, failing to recognize that a management position of the sort that he described would require excellent mental status.  It is difficult to determine whether the patient’s poor judgment and insight represent some preexisting or premorbid tendency.  Obviously, further evaluation would be necessary.

CONCLUSIONS AND IMPRESSION

To conclude, this 62-year-old victim of cerebrovascular accident with resulting left hemiparesis was recently evaluated.  On mental status evaluation, reduced insight and judgment and
short-term memory were displayed.  Some evidence of articulation difficulty in speech was also displayed.  For example, in
45 seconds the patient was able to produce only 5 words starting with the letter “f.”  A normal result for an individual of his age would be approximately 15 words.  At the present time, it is recommended that further formal psychometric testing is indicated.  We will try to complete as much testing as possible tomorrow in the a.m. prior to the patient’s discharge.  Whatever remaining assessment needs to be conducted will be arranged on an outpatient basis.

Thank you for this referral.  As always, please contact me if I might be of further assistance.

FOOTNOTE

Line 17 (Page 1).  The dictated dash was changed to a comma for proper punctuation.

Line 29 (Page 1).  The phrase orientation x4 means orientation to person, place, time, and future plans.

Line 31 (Page 1).  Appears was changed to appear for correct subject-verb agreement.

Line 35 (Page 1).  Represents was changed to represent for correct subject-verb agreement.

Lines 1-2 (Page 1).  CVA was translated in the Impression for clarity.

Line 6 (Page 1).  The dictated paragraph was not introduced.