Case Study: 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 …show more content…
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.
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.
He is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia.
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.