Age: 31.0
Sex: M
Vaccine: FLUN3
Symptoms: Orthostatic intolerance, Pain in extremity, Palpitations, Panic attack, Paraesthesia
Clinical narrative: 31-year-old, RHD. He exercised up to 5-6 days per week, including weight training and running 1-3 miles. He denies any head trauma or other injuries or any drug use. When patient woke up on 15 OCT, he felt good and was getting ready to go to the gym. He noted his fingers on his left side felt like they were in warm water and then this sensation "exploded across (his) body". He then had to "fight to stand" due to weakness and ended up slumping down to the floor, where he could not initially talk or move. While on the floor, he felt like his body was "wrapped in a warm blanket". He denies any pain; he describes sensations as being "very comfortable". He is not sure how long he was paralyzed on the floor, but estimates it was probably < 15 minutes and definitely not more than 30 minutes. When he was able to move, he crawled toward the door, and then he was able to stand in the doorway and call to his girlfriend. He then tried walking and recalls walking with a limp on his left side. While he was in the doorway, where his girlfriend met him, he noted that the things he was looking at were like "strobe light motion", which was fleeting and only lasted a couple of minutes. Describes bright lights flashing and any movement looking like movements when lights flashing off and on - robotic or jerky. By this time, his mind was racing and he was worried he might be having a stroke or heart attack. His girlfriend called 911. He thought he should take an aspirin, but when she could not find any aspirin, he took a MOTRIN. He then went back to his bed. He denies any loss of consciousness, bowel or bladder dysfunction, or chest pain. The second episode occurred after police officer arrived in response to the 911 call, and patient had taken about 5 steps toward the front of the house where the policeman was, and before getting there, he felt like "a robot powering down" and slumped to the floor again. This time, a warm sensation did not start in his left hand, but he felt the sensation all over. The EMTs arrived and helped him to his feet. The third episode occurred shortly after, when he felt like he had no strength throughout his whole body and went to the floor again. The EMTs took his vital signs and directed him to squeeze their hands. Unless he really concentrated, he could not squeeze with his left hand. His left arm started moving randomly and his fingers were "waving back and forth" while he was lying on his back being checked by the paramedics. These random movements of his left arm resolved before being transported to the hospital via ambulance and did not recur. Patient felt a disconnect between thoughts and actions related to his LUE. If he thought of any type of movement, his LUE would perform this. (Example: turning to check if EMT was behind him, and in actuality, he was grasping EMT's shirt with left hand). He was aware of events occurring in the ambulance. He was able to follow EMT's instructions, except he could not move his left leg ("completely paralyzed" for about 20 minutes). He could move his left arm. His fingers on his left hand felt warm and he noted a change in its color, which he thought was due to decreased blood flow - kind of "grayish" compared to the rest of his skin. His left forearm had a tingling sensation. By the time he got to the ER, he felt a little incoherent, lightheaded -like he was "floating"; he was also very weak. He recalls his heart racing - not skipping beats or irregular beats, but "like heart was going to beat out of chest"; he also recalls elevated blood pressures while in the ER (143/77-80-20), and experienced a migraine headache with associated flashing aura after he had been in the ER for more than 1 hour. Hospitalized. Admission Differential Diagnoses of AMBIEN side effect/possible emergence reaction, Atypical migraine, Seizure Disorder, and Panic attack with hyperventilation. By the time of exam in ER and admission physical, patient's physical exam was normal, but there was an ER notation saying "felt like he could not move and got up 3 x and fell back down". Discharge summary included Neuro Exam "completely nonfocal with normal sensation and strength". Discharge Summary Differential Diagnoses were AMBIEN vs. cataplexy vs. hypokalemic periodic paralysis, and complex partial seizure. Patient's AMBIEN was discontinued, he was started on potassium supplements, and he was referred for a repeat EEG and to see an Epileptologist. Despite ER entry noting... "almost back to his status quo... He was able to get up and ambulate without any residual effect... L sided weakness resolved" and Discharge summary noting "now mainly feels a little bit weak but mostly back to normal", patient reports being bedridden for 1-2 weeks after his hospitalization in OCT 2009. He stayed at home and mostly slept. He initially had problems getting around due to weakness and inability to sense where his feet were. He could not touch his left index finger to his nose with his eyes closed. He reports difficulty with balance lasting for 1-2 months. (Had to teach himself to walk again.) Nerve conduction studies/EMG were completed on 22 OCT 2009 to evaluate neck pain and numbness in left arm and left leg, which were within normal limits, with no evidence of neuropathy or radiculopathy in the tested limbs. Initial outpatient EEG completed on 20 OCT 2009 was reported to have "sharp waves" and patient was diagnosed as possibly having epilepsy. (Report Conclusion: EEG in awake and drowsy states shows intermittent generalized sharp waves and occasional spikes during post hyperventilation state.) However, after evaluation with the Epileptologist, and third EEG, (Sleep-deprived study on 29 JAN 2010 - normal EEG during awake and light-sleep states), it was determined that he did not have epilepsy. At that time, patient reported tingling and numbness in his left fingers, as well as unsteadiness. Patient was seeing a chiropractor in OCT 2009, who noted he was experiencing tingling and numbness in his left forearm, which patient now reports has never gone away, but decreased in intensity. He describes this sensation as his forearm feeling "like a chunk of wood". In AUG 2011, Int Medicine documentation notes "continues to have arm pain...feels like screws in fingernails"; also notes "mental fog" which had not specifically been mentioned prior or since, other than feeling "drunk" or euphoric. Patient has not had similar episodes to those he experienced in OCT 2009, but in SEP 2010, he had an episode where he experienced a strange sensation of "sinking" or "falling through his bed" where he followed up with his Neurologist. He did not become weak or paralyzed with that episode, but described sensation of "being dipped in warm water" from the knee down on his left leg; sensations described as coming on and fading quickly. At that time, patient was reporting occasional headaches which were similar to the headaches diagnosed by an Ophthalmologist in 2008 as "optical migraines". Patient typically had 2 of these incapacitating headaches per year between 2008 and OCT 2009, sometimes with associated visual symptoms (strobe light movements). Dr. also mentioned patient experiencing a sensation of "roving numbness". Since SEP 2010, patient had undergone evaluations to include sleep studies, which were recommended by another Neurologist to evaluate for narcolepsy. Those results were consistent with sleep apnea, but patient initially was unable to tolerate CPAP. With repeat sleep study in SEP 2012, which was consistent with OSA (AHI 52.8), patient has started using biPAP and seems to be tolerating. Patient has been evaluated by Neurology for his headaches, which were diagnosed in SEP 2012 as "probable migraine with aura". Working at computer and reading may trigger headaches, especially those associated visual symptoms. Patient completed Neurology evaluations in 2012 - Please review AHLTA notes dated 7 SEP and 19 DEC 2012. Headaches thought to be classic migraines with aura, and a C-spine MRI was ordered to rule out cervical spinal cord lesion as possible cause of patient's temporary weakness. (24 JAN 2013, MRI, C-spine normal except, "C3-C4: Mild right uncovertebral joint hypertrophy. No spinal stenosis No foraminal narrowing.") In OCT 2010, patient was evaluated for possible syncopal spells, TIA or stroke at cardiovascular office. His evaluation at CV office included a standard 40-minute tilt test which was consistent with mild orthostatic intolerance and mild resting bradycardia, but there was no evidence of neurocardiogenic syncope, FLORINEF was recommended, but patient never initiated. Patient's evaluation also included a TEE which showed small PFO with mitral valve prolapse and mild mitral regurgitation. Additional follow up in DEC 2011 was prompted after patient was commuting to work and he experienced his heart was beating exceptionally hard - "going nuts", and his hands were shaking like he was "ODing on adrenaline". He had to pull off the road because he was physically unable to drive, so he called his supervisor to take him to the ER, and after a couple hours, his symptoms resolved without treatment. (This episode did not involve any paralysis or paresis.) At the time of CV evaluation the day after the episode, recommendations included consideration of implanting the Reveal Insertable Cardiac Monitor if another episode occurred. Patient had more recent Cardiology evaluation in DEC 2012 for 2nd opinion regarding a possible cardiac etiology underlying his episodes of paralysis and lightheadedness - Please refer to AHLTA notes dated 10 and 27 DEC. Documentation describes patient feeling lightheaded, "drunk" or euphoric, sometimes relating to heart pounding and cold sweats and sometimes associated with left hand and foot numbness with episodes occurring most days and varying in intensity. No related loss of consciousness, flushing or fatigue or confusion after event -> 2 week event monitoring, which did not support symptom complex being related to heart rhythm disturbance. PMH: Childhood allergies, for which he received AIT during childhood. As an adult has experienced allergic rhinitis with symptoms controlled with medications. History of allergies to pollen, dust mites and cats. Additional Allergy evaluation in NOV 2012 - patient not felt to be candidate for AIT at present No chronic illnesses. No previous hospitalizations except as related to acute episodes in OCT 2009 and surgery. Allergies: No known medication, food, latex or inset sting allergies. Surgical History: 2003, Colonoscopy with colonic mucosa and tubular adenoma. Subsequent Medical History (since OCT 2009): MAY 2010, Conjunctivitis left eye AUG 2010, Chronic Allergic Conjunctivitis per Optometry OCT 2010, Obstructive sleep apnea, as above DEC 2010, Septoplasty, turbinate reduction and T&A surgery JUN 2011, Left elbow injury post-fall. MRI normal; completed Ortho evaluation and received steroid injection JAN and MAR 2012, conjunctivitis of left eye MAR 2012, ganglion cyst of right wrist -> aspiration x 2 SEP 2012, prolonged right shoulder pain after lifting weights; MRI demonstrated rotator cuff tendonopathy and possible non-displaced labral tear -> PT. Current Medications: ASA 81 mg daily, XYZAL daily, Ciclesonide Nasal Spray daily, VISINE eye drops daily, OTC protein shakes on regular basis. Social History: Nonsmoker Drinks less than two drinks once/week. Works as Public Affairs Officer. Family History: No family history of neurological or neuromuscular disorders or sudden death Mother - 60, in good health, Hx of conduction disorder, s/p removal of GB Father - 59, in good health, Hx of heart arrhythmia Brothers x 5 - all in good health PGF diagnosed with prostate cancer at age 90.