Case Study: Chief Complaint

901 Words 4 Pages
Chief Complaint
Follow up on new onset seizure.

History
Patient is a 58-year-old right-handed white male who presents with his ex-wife for followup after inpatient evaluation for new onset seizure. I did review the H&P and discharge summary, the initial neurology consult done by Robin Kass, MD and my follow up notes. I also reviewed the EEG report and reviewed the scans myself. This is an individual who has had a hypoglycemic brain injury in 2008 resulting in an induced coma for a full month, then rehabilitation. It took him two years for full recovery. He did have residual personality change and does walk with a wide base, unsteady gait. He also did suffer a fall with a brain bleed about two to three years ago and was hospitalized for few
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He does drink as noted above, but has stopped drinking since his seizure. He is divorced, but on good grounds with his ex-wife, who as I mentioned presented with him today.

Family history
Cancer.

Past Medical History
Diabetes, type I.
Hypoglycemic event in 2008 resulting in right frontal lesion and slight left-sided weakness.
Hypertension.
Hypercholesterolemia.
Diabetic peripheral neuropathy.
Intracranial hemorrhage due to a fall.
Allergies
Penicillin.

Medications
Insulin, Mestinon 60 mg b.i.d., Crestor, midodrine, Lexapro, aspirin 81 mg, Keppra 500 mg b.i.d.

Examination
Constitutional
Respirations 12. Pulse 67.

General
He initially was in no obvious distress, but at the time that I actually examined him, he was very anxious regarding his driving restrictions.

Mental Status
He is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia.

Cranial Nerves
Visual fields full to confrontation. Extraocular muscles intact. Normal facial symmetry, sensation, and movement. Normal shoulder shrug. Tongue and uvula were midline.

Motor
Was 5/5 strength, but with a left pronator drift and decreased fine finger motion on the left.

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