Today I have seen your patient in Neurosurgical consultation at your request.
As you know, she is a very pleasant forty-year-old, the Right-handed lady who comes in with a history of seizure-like Episodes beginning in January of 2012. These seizures consist of a sense of unreality and a feeling as though she were observing herself as an actress on a stage. Before the onset of or associated with these seizure-like episodes, she has noted a smell of heavy fragrant flowers. She describes the smell of the flowers as slightly unpleasant almost funereal. Each of these so-called seizure states lasts only a few seconds and is followed by a tremendous feeling of unreality. This is also associated with a great fear that she will not be able to move and she always gets up and walks around afterward to make sure she is not paralyzed. In the episode, there is no loss of cognitive ability and she is able to converse with her husband, and she has a virtually total recall for the entire episode. She had episodes as described in January and February of 2012 fourth in March and five in April.
There is a story of a mild head injury at age ten, and apparently, she was in a moderately severe motorcycle accident about fifteen years ago which resulted in a broken mandible. There is no family history of seizures.
PAST MEDICAL EXAMINATION
The neurological examination at this time is essentially normal. The extraocular movements and Fundi show no abnormalities. The visual fields and confrontation testing are intact. There is no Babinski sign. The only abnormality that I could detect in the entire examination was a stiffened right shoulder, which she tells me came on after a lengthy game of tennis. I could palpate no masses over the head, and there were no audible bruits over the head or either carotid bifurcation.
She has been on a dose of thirty milligrams of Phenobarbital bid and did not care to add any Dilantin. The Phenobarbital keeps her in a drowsy state. Consequently, she is not able to think creatively or participate in sports activities.
She brought with her the skull X-rays and brain scan taken at University hospital, and I have reviewed them. In my opinion, they are within normal limits. In addition, she brought with her several Eeg records which I have gone over. The Neurologists summary is enclosed.I thought there was a slight abnormality present in the right temporal area. At this time, I do not believe there is evidence of Intracranial Mass Lesion, or Neurologic Focal deficit has total recall for the entire episode. Thirdly, there is the fact that she has no Postictal Abnormality.
My tendency at this time would be to gradually switch her over to Dilantin thirty milligrams tid and in addition place her on Diamox 125 milligrams each morning. I suggest the Diamox because she tells me that the seizure episodes tend to come on within a few days of her menstrual periods.
REVIEW OF SYSTEMS
We have agreed that if she is not markedly improved within a period of one month on this regimen, she would come into the hospital for four vessel Angiography.
Thank you for the privilege of seeing this interesting patient and for thinking of me in connection with her problems.
Maximous Payn.Doctor. M.D., F.R.C.P. (C).References
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