CLINIC:
DATE:
ATTENDING PHYSICIAN:
Pediatric Neurology Clinic
11/2/2008
Michael Edwards, M.D.
HISTORY OF PRESENT ILLNESS: Xxxxxx Xxxxxxx was seen on an semi-urgent basis
on 11/2/2008. His mother called indicating he had 2-1/2 months' worth of
headaches associated with lethargy and occasional nausea. In the past,
headaches had not been a significant problem.
Xxxxxx and his mother state that just prior to the onset of school, sometime
in August of 2008, he began having headaches. He noted that when headaches
began in school and when he came home he was exhausted, tired and needed to
sleep. When he would wake up at approximately 5 p.m., his headache was
improved, but still present.
He did have some difficulty with a seizure disorder. Dr. Tharp has been
managing his medications. He had a trial of Dilantin, which was not
effective. He was placed on a small dose of Depakote, but had recurrent
seizures and now is back on his prior Depakote dose and appears to have
infrequent to no seizures.
He denies any new deficits. His prior fixed deficit, which is consistent with
some right hand spasticity and mild right leg spasticity is stable.
Xxxxxx lists his headaches as a 5 or 6/10. He also has dizziness associated
with it. A nap sometimes helps. It is sometimes helped mildly by the use of
Tylenol.
Moving his head around or activity makes the headaches worse. He likes to lie
in a quiet room. The headaches can last hours, but in general are present
almost all of the time. They have not resolved over the last few months and
continue to this date.
PHYSICAL EXAMINATION: On examination he is awake and alert. His cranial
nerves are intact. His relevant physical findings are motor tone, bulk and
strength at 5/5 in all muscle groups. He is slow in finger tapping with his
right hand. He is left handed. He ambulates with a normal gait and a narrow
stance and he can heel and toe walk without difficulty. He can tandem walk
with minimal deficit.
We did obtain an emergent MR scan to rule out recurrence of his tumor and/or
cyst. The new scan dated 11/1/2004 was compared with 5/3/2004. There is no
change in the size and signal characteristics of the area of hemosiderin
staining. There was no recurrent cyst or recurrent tumor. No mass effect,
shift or other lesions noted.
MEDICATIONS:
Present medicines are Depakote 750 mg twice a day for a total of 1,500 mg per
day.
ASSESSMENT AND PLAN: Presently, we have eliminated tumor as a cause for his
headaches. I have suggested that we obtain some baseline endocrine studies,
which have not been done in the past. Therefore, we will check his cortisol,
thyroid and testosterone. In addition, I have asked that they check back in
with Dr. Barry Tharp, their primary neurologist, to assess other possible
etiologies of his headaches, and in the interim for him to keep a
conscientious headache diary.
I plan to see him back in 6 months and will update this note following
acquisition of his hormone studies.