Other reactions to severe stress Abnormal reflex Asperger's syndrome Weakness
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROLOGY
 
Allergies: 
No Allergies/ADRs on File
 
Attending: ___.
 
Chief Complaint:
left sided weakness
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
The patient is a ___ year-old male with PMH notable for Asperger
syndrome/Autism spectrum who presents as a direct transfer from
OSH (___) for L-sided weakness, L-sided hemi-spasticity,
L-sided hyper-reflexia and involuntary L-sided muscle
contractions.

Mr. ___ was in his usual state of health until 2 days prior to
admission (evening of ___ when he developed intermittent,
mild R-sided headache, light-headedness and light-sensitivity. 
He
reports he had several brief episodes of headache which
self-resolved. He was able to sleep that night, however woke up
on ___ with persistent right-sided headache and generalized
malaise. He describes the headaches as a ___ with regards to
severity, localized to his R temple and associated with
photophobia. He describes the sensation of traffic lights on the
street being excessively bright, and notes that he normally does
not have a history of headaches prior to this. 

The headaches and malaise persisted through ___, at
which point the patient asked his father to drive him into work. 

He works at a desk job and was able to work for approximately 3
hours from 6pm-9pm but noted progressive numbness in his LUE and
LLE (up to his knee) over this time period. At the end of this
time period (approximately 9pm on ___, patient LLE/LUE 
numbness
progressed to ___ LLE/LUE weakness where he remembers he
distinctly could not stand up from his chair. This sensation
persisted, and was followed by his leg shaking violently,
followed by shoulder jerking. Patient was able to ask for help
from his colleagues but otherwise does not clearly remember the
ensuing time period following the onset of these symptoms,
however he does remember being assessed in the ambulance by the
paramedics, which he was told was about 20min after the onset of
his symptoms. Following this event, he continued to have left
upper and lower extremity weakness, and was brought to ___
for further evaluation.

Patient was questioned without his parents in the room to obtain
additional history. Of note, Mr. ___ recently started this new
job. He reports mild stress associated with work but does not
believe this is impacting his daily functioning or pathological. 

He further denies any recent illness. Denies recent upper
respiratory symptoms, fevers/chills, and diarrhea. Denies any
history of prior episodes of weakness, denies any prior history
of periods of visual loss. No recent drug use; he did use
marijuana at ___. He reports feeling happy at home
with no stressors apart from this recent job. He is not sexually
active. No recent travel. Denies any unusual ingestions. 

At ___, he states that his L-sided weakness slowly
improved. His examination per his OSH records was notable for
weakness of the left arm and leg (documented only as ___ in L
upper extremity, and "unable to straight leg raise" in the L
lower extremity), L sided hemispasticity, L sided hyperreflexia,
and possible fasciculations. For further workup, he had a CTA
head/neck which was unremarkable. He had an unremarkable initial
lab workup as well, with normal basic metabolic panel, LFTs, and
CBC. Serum tox screen was negative for salicylates, 
acetaminophen
and ethyl alcohol. He was evaluated by the neurologist at ___ who expressed concern for transverse myelitis and
recommended transfer to ___ for further evaluation.  

On neuro ROS, the pt denies current headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia, 
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies bowel or bladder
incontinence or retention. 

On general review of systems, the pt denies recent fever or
chills.  Denies cough, shortness of breath.  Denies chest pain 
or
tightness, palpitations.  Denies nausea, vomiting, diarrhea,
constipation or abdominal pain.  No recent change in bowel or
bladder habits.

 
Past Medical History:
Asperger syndrome/Autism spectrum 
 
Social History:
___
Family History:
- ___ Sister has a history of uncontrolled right-sided 
tremors/dystonia with no clear diagnosis beginning at ___, 
followed by Dr. ___ at ___. 
- Mother with history of Anxiety.
- No fam hx of seizures, strokes or neurologic malignancies
 
Physical Exam:
Vitals: T:99.9 BP: 103/52 P:70 RR:17 SaO2: 99%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. 
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G 
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Speech fluent, no dysarthria. Follows 
midline
and appendicular commands.

Cranial Nerves: EOM full with conjugate gaze, no nystagmus. Face
symmetric, tongue midline. V1-V3 equal to light touch. Hearing
intact.

Motor: Normal tone and bulk
+Intermittent spasms of his LLE and LUE that disappear with
distraction
  Delt Bic Tri WrE FFl  FE  IO   IP   Quad  Ham   TA   ___
L  5    ___   5    5   5    5     5    ___      5     
5
R  5    ___   5    5   5    5     5    5     5      5     
5

Sensory: intact to light touch bilateral 

-DTRs: 
  ___ Tri ___ Pat 
L  3  3    3    2   
R  3  3    3    2   
Plantar response was flexor bilaterally.

Coordination: No intention tremor, no dysmetria. Heel-knee-shin
was jerky, tremulous on left but smooth throughout. 

Gait: Able to bear weight bilateral. Negative Romberg. 

 
Pertinent Results:
___ 09:19PM   GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-140 
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
___ 09:19PM   ALT(SGPT)-8 AST(SGOT)-12 CK(CPK)-60 ALK 
PHOS-82 TOT BILI-0.5
___ 09:19PM   CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 09:19PM   VIT B12-448
___ 09:19PM   %HbA1c-5.0 eAG-97
___ 09:19PM   RHEU FACT-<10 CRP-0.3
___ 09:19PM   TSH-3.8
___ 09:19PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:19PM   WBC-4.9 RBC-5.12 HGB-15.4 HCT-44.7 MCV-87 
MCH-30.1 MCHC-34.5 RDW-11.9 RDWSD-38.5
___ 09:19PM   PLT COUNT-242
___ 09:19PM   ___ PTT-29.6 ___

MRI Brain ___
IMPRESSION:1. No concerning intracranial lesions identified.
2. No acute infarction or hemorrhage.

MRI Spine ___
IMPRESSION: 1. No definite cord signal abnormalities identified. 
 Slight apparent
increased STIR signal abnormality along the upper cervical cord, 
is likely
artifactual in etiology, as no correlate was seen on the axial 
T2 weighted
images.  No concerning enhancing lesions are seen.
 
Brief Hospital Course:
___ was admitted to ___ after he developed left sided 
weakness while at work on ___ evening.  At ___ there 
was concern that he could have acute flaccid myelitis, so he was 
transferred to ___ for further evaluation and treatment on 
___.  

Upon arrival to ___, history and exam was confirmed.  Briefly 
on ___ evening he drove home from work and noted that his 
left side felt odd and that he was more sensitive to the 
headlights. ___ evening he still felt weak on his left 
side, so his Dad drove him to work when at approximately 9pm 
during his work break he felt as if he was unable to stand. He 
then developed left sided shaking of his extremities and a right 
temporal headache.  After the weakness started, he had some left 
sided paresthesias that started in his foot and ascended 
upwards. During this episode which last 20minutes, he never lost 
consciousness, he just became very anxious. EMS was called and 
he was brought to ___.

At ___, a MRI spine was completed that was normal.  He was 
evaluated by Physical Therapy was deemed stable for discharge 
home with outpatient physical therapy with a rolling walker, as 
well as outpatient neurology follow up.

Transitional Issues:
Recommend Cognitive Behavior Therapy
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications

 
Discharge Medications:
None
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Stress Induced Weakness 
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr. ___,

You were transferred from ___ to the Neurology Service at 
___ for evaluation of your left sided weakness.  Your exam was 
reassuring and you continued to show improvement in your 
strength and function.  You had a MRI of the brain and spine 
that did not show any abnormalities.  Overall, your evaluation 
was normal and reassuring.

Your doctors think that your episode was likely due to stress.  
Neurologic symptoms can sometimes be due to non-neurologic 
issues. It is an increasingly well recognized condition.

There is a website: ___/ that offers a 
lot of helpful information regarding these conditions and 
issues.  While it will not all apply to you, it may be helpful.

It is not uncommon for people under new or different stresses to 
respond differently, including with Functional Neurology 
Symptoms.  The diagnosis was supported by both your very normal 
and reassuring Neurologic examination and imaging.  

It is important that you follow with neurology to help guide 
you.  Dr. ___ Dr. ___ both saw you in the 
hospital) will see you in clinic in ___.   Additionally, 
outpatient therapy and psychiatry follow-up  is often critical 
in helping you with this issue long term.

You were examined by physical therapy who you were safe to go 
home, but recommended outpatient physical therapy to continue to 
encourage improvement.

Thank you for allowing us to participate in your care,
___ Neurology
 
Followup Instructions:
___

{'left sided weakness': ['Weakness'], 'intermittent spasms of his LLE and LUE': ['Abnormal reflex'], 'right-sided headache': ['Other reactions to severe stress'], 'light-headedness': ['Other reactions to severe stress'], 'light-sensitivity': ['Other reactions to severe stress'], 'numbness in his LUE and LLE': ['Weakness'], 'L sided hemi-spasticity': ['Abnormal reflex'], 'L sided hyper-reflexia': ['Abnormal reflex'], 'possible fasciculations': ['Abnormal reflex'], 'Asperger syndrome/Autism spectrum': ["Asperger's syndrome"]}