Case Study: Chief Complaint

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Chief Complaint
Follow up on new onset seizure.

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

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

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

Respirations 12. Pulse 67.

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.

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

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