Neurology Clerkships
Case 33  
Author: Gregg Meekins, MD
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This is a 16-year-old male who presents to the clinic having had an episode of loss of consciousness approximately one week ago. The event occurred shortly after awakening and while brushing his teeth. His mother heard him groan loudly and found him on the floor in an unconscious state. Per the report of his mother, there was rhythmic jerking of his arms and legs lasting no longer than a minute in duration. He remained in an unarousable state for approximately five more minutes with slowed, heavy breathing.

Paramedics were summoned to the home and found the boy in a confused and combative state and transported him to a local emergency room for evaluation. He recalls awakening in the emergency room and receiving a blood test and a “special” x-ray of his brain. He was then discharged from the emergency room and told to follow up with a neurologist. A clinic appointment was made upon referral from the emergency room. Unfortunately, the clinic has not yet received a copy of the emergency room evaluation.

This patient denies previous episodes of loss of consciousness, vertigo or lightheadedness. He denies history of headaches, episodic weakness or sensory loss. He has had several episodes of isolated and brief whole-body “jerks” which have occurred while eating his breakfast.

Review of symptoms is otherwise unremarkable.

PMH: None

Medications: None

Allergies: NKDA

Family History:
Father with elevated cholesterol. Mother in good health. No history of neurologic disease in first degree relatives.

Social History:
He is a sophomore in high school receiving good grades. Has one younger sister in good health. Denies alcohol, tobacco or recreational drug use.

BP 105/60   HR 70   T 37.0°C
General: Appears well dressed and nourished, no apparent distress.
Mental Status: Comprehension and fluency intact. Alert and Ox3.
HEENT: Head is normocephalic and atraumatic. Neck is supple with full range of motion and no adenopathy. Funduscopic examination is normal. Pupils are equally reactive to light and accommodation. Visual fields are full to confrontational testing. extraocular movements are full. Facial sensation and strength is symmetrically normal. Hearing is symmetric. Palatal elevation is symmetric with normal gag reflex. There is symmetric strength with head turn and shoulder shrug. Tongue protrudes on the midline.
Motor (Power/Tone/Bulk): Normal symmetric tone and bulk of muscles. Strength is 5/5 in the upper and lower extremities.
Sensory: Symmetrically intact to vibration and pin in the extremities.
Reflexes: 2+/4 symmetric in the biceps, triceps, brachioradialis, patellar and Achilles tendons. Toes are downgoing (flexor) to plantar stimulation.
Coordination: Normal finger-to-nose testing and rapid alternating movements.
Abnormal Movements: None
OtherOrgans: Non-contributory

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