Case 43 - History - Neurology Clerkship

Case 43

Author: Sidney M. Gospe, Jr., MD, PhD

This is a 29 month-old boy who presents to his primary care physician for a well child examination. Mother reports that the boy has not developed appropriate language. He only has about eight words in his vocabulary and he does not put two words together. She believes that his hearing and vision are normal. His motor development has been appropriate and he has had no regression in his behavior or development.

PMH: The child was born at 39 weeks gestation and was the product of an unremarkable pregnancy, labor and delivery. The child has had four seizures at 11, 15, 19 and 23 months of age. Three of these events were in the setting of an acute febrile illness.

Medications: None

Allergies: NKDA

Family History: The parents have three other children who are developmentally normal and who have not had seizures.

Social History: Both parents have completed college and are employed.

Physical:
BP 92/68 HR 95 T 37.1°C RR 18
General: Weight, length and head circumference are at the 25th percentiles.
Mental Status: The boy has an alert expression and he is variably cooperative with the examination. He follows some commands via mimicry but he does not follow verbal commands and he does not use any words other than “mama”. He understands the meaning of the word “no” when it is used by his mother.
HEENT: PERRL, EOMI, no nystagmus. Facial sensation and strength are normal. Palate and tongue are at midline.
Motor (Power/Tone/Bulk): Normal
Sensory: Withdraws extremities to tickling.
Reflexes: 2/4 at biceps, brachioradialis, knees and ankles. Plantar responses are downgoing to plantar stimulation.
Coordination: The boy reaches for toys without dysmetria.
Gait: The boy’s gait is appropriate for his age.
Abnormal Movements: None
Other Organs: There is no organomegaly, and there are no dysmorphic features. There are several hypopigmented macules noted on the thighs, abdomen and thorax.