861 WordsMay 4, 20154 Pages
PEDIATRIC NEUROLOGY CLINIC CONSULT_____________________ Patient Name: Grace Pereira PCP: Reed Phillips, MD Patient ID: 017990 DOB: 06/24/2007 Age: 7 Sex: F Date of Exam: 05/05/2015 Reason for Visit: Follow-up of behavior, patient accompanied by mother, records are unavailable. HISTORY: Grace a 7-year-old girl has a history of severe behavioral problems, ADHD, bipolar disorder, borderline mental retardation, and significant past medical history of congenital hydrocephalous associated with myelination defect on MRI. Mother records no new concerns. Mother notes some brief improvements in the patient’s impulsiveness and distractibility after starting Neurontin. However, she feels that it is no longer effective.…show more content…
Tympanic membranes flat pale. NECK: Supple without mass or lymphadenopathy. CHEST: Lungs clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft with normal active bowel sounds, (Continued) PEDIATRIC NEUROLOGY CLINIC CONSULT Patient Name: Grace Pereira Patient ID: 017990 Date of Exam: 05/05/2015 Page 2 non-distended, no hepatosplenomegaly, no mass. EXTREMITIES: No clubbing, cyanosis, or edema. Warm well perfused with +2 pulses symmetrically. NEUROLOGIC EXAM: Sensorium intact. Cranial nerves II thru XII intact with the exception of Cranial nerve VIII on the right ear. Normal strength, normal tone, no ticks or tremor, normal gait, and stance. Deep tendon reflexes +2 symmetrically throughout. X-RAY DATA: MRI with MR spectroscopy of the brain was performed on 04/20/2015, which reports stable appearing non enhancing white matter abnormalities as described. The findings are felt to most likely represent sequelae of PVL a demyelinating disease, which are felt to be much less likely as are sequelae of an old infection. Normal MR spectroscopy within the right basal ganglia and right centrum semiovale white matter. Mild inflammatory sinus changes. LAB DATA: Summary of laboratory findings for the past year includes the following: 1. 02/07/2015 TORCH titer is negative except for positive HSV-1 IgG. Biotinidase normal, fragile X PCR negative, chromosome analysis 46, XX normal


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