March 14, 1983
Ralph Moloshok, M.D.
73 East 90th Street
New York, New York 10028
Dear Dr. Moloshok:
This letter will summarize a neurologic examination performed on ***** today in the presence of his father. He is currently 16 years of age, and being evaluated because of a seizure.
***** states that he was doing well until Wednesday, March 9th, after coming from an appointment to see Dr. Robert Porter. ***** as diagnosed as being clinically depressed, and it was recommended that he should start Elavil, 25 mg. at bedtime. ***** began these on Wednesday, March 9th, and he took his second dose Thursday March 10th at bedtime. The following morning, his father went in to wake *****, and then left the room. Shortly thereafter, he heard some noises coming from the room, went back in and noticed that ***** was in the midst of a generalized tonic-clonic seizure, with his teeth clenched, and salivating. This episode lasted approximately 15 to 20 seconds. It was noticed that ***** bit his tongue, but did not experience incontinence. He immediately went back to sleep, and slept for the remainder of the day. When he awoke he had a headache, and felt nauseous.
Since that time ***** has complained of staring episodes, or instances during which he is staring and unresponsive, and these are happening on 1 to 2 occasions during the day. Most recently, ***** was out walking his dog when he stopped in the middle of Lexington Avenue and said that he was in a "daze." Fortunately, according to *****, somebody tapped him on the shoulder and brought him back and brought him across the street. In retrospect, His father (sic) now states that he has been observing ***** in these staring spells for approximately the past month, but he thought ***** was fooling around and didn't take them seriously.
***** denies any other symptoms such as headaches, dizziness, vertigo, visual or hearing complaints, difficulty speaking, thinking, chewing or swallowing. He denies motor problems, coordination problems, or gait problems. He also denies difficulty with his bowels or his bladder, and aside from the fact that he appears clinically depressed, he has no other complaints.
*****'s past medical history is very significant because he had an episode which was described as a febrile seizure occurring at age 7 to 8 years. He also states that when he was about 10 years old, and visiting his mother in Washington, he thinks he experienced a seizure at that time as well.
***** has had a series of school-related difficulties, and is currently repeating the 9th grade at the McBurney School. He also is described by his father (sic) as having been hyperkinetic as a youngster. There is a negative family history for seizures, or other neurological problems on either side of the family. ***** perinatal and developmental history, according to his father (sic) is entirely unremarkable.
*****'s mother died of a myocardial infarction at age 43, in 1978. His father is currently 56 years of age, in good health, and he works as a free-lance writer. There was also (sic) a baby girl who was born several weeks prematurely, and who died at 2 weeks of age. This episode occurred prior to *****'s birth.
On examination: ***** is a well developed, well nourished, and tall young man in no acute distress. He was alert, awake, and cooperative during the examination. ***** exhibited mild difficulty performing math skills, but had no significant learning (sic) disabilities picked up, nor did he exhibit perceptual motor problems.
***** measured 71 inches in height, and he weighed 168.5 pounds. His head circumference measured 56 cm. His general physical examination was unremarkable.
Mental status testing was normal in all regards. Cranial nerve testing revealed a visual acuity of 20/20 (OU.), uncorrected, with full pupillary movement and full extraocular movement in all directions. There was no nystagmus, the fundi were entirely unremarkable, including the discs and maculae, and there were good venus pulsations noted bilaterally. Both corneal responses were intact, there was no evidence for facial weakness or asymmetry, hearing was intact bilaterally, and the lower cranial nerve examination was unremarkable.
Motor examination revealed normal tone and strength throughout, without evidence for drift or adventitious movement. The deep tendon reflexes were 1 to 2+ and symmetric, and both plantar responses were flexor. Sensory examination was normal.
Coordination testing revealed normal finger-nose-finger, finger-to-finger, and rapid repetitive alternating movement bilaterally. His gait was normal, he was able to walk on his heels. toes, and perform tandem gait without difficulty. Hopping, skipping, and balancing on either foot was also equally well performed. The Romberg test was negative.
Examination of the skin revealed one small cafe-au-lait spot just outside the axilla of the right arm, and a small strawberry hemangioma was noted at the base of his neck. There was no evidence for scoliosis, and the remainder of his general physical examination was unrevealing.
In summary, ***** is a young man who has experienced a generalized tonic-clonic seizure, possibly precipitated by Amitryptiline. However, in view of the past history of at least one atypical seizure occurring with fever at the age of 7 or 8 years, and a possible second seizure at the age of 10 years, it seems reasonable to assume that ***** has an underlying seizure diathesis substrate.
***** underwent hyperventilation for a period of 4 minutes, without precipitating any clear-cut evidence for petit-mal or other seizure activity. Therefore, I feel that his staring and "spacing out" episodes are probably psychologically based, and do not represent true seizure activity of any kind, especially since they are not associated with any other stereotyped movements of any kind according to his father. (sic)
Therefore, it is recommended that ***** begin taking Dilantin in a dosage of 300 mg. at bedtime, on a daily basis. Additionally, I have recommended that ***** have an EKG examination as well as a CTT scan with contrast, but his father (sic) states that he is a member of HIP, and therefore will try to arrange these tests through his HIP center, and have the results forwarded to me. It was also recommended that ***** should have a blood serum level of Dilantin as well as a CBC and SMA-12 obtained in approximately 2 to 3 weeks time.
Thank you for the courtesy of this referral, and if I can be of any further assistance, please don't hesitate to contact me.
David M. Kauman, M.D.
Clinical Assistant in Pediatrics & Neurology
The Mount Sinai Medical Center