DIALOGUE

[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you
[patient] i'm okay i guess
[doctor] hey dad how are you doing
[patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you
[doctor] okay alright so karen have you felt the twitch
[patient] yeah well i mean i feel my face sometimes
[doctor] yeah and do you have any pain when it happens
[patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens
[doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face
[patient] sometimes and then it moves and then i feel better
[doctor] okay okay and so so dad how often are you seeing the twitch on karen
[patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks
[doctor] okay so karen how is how is how is soccer
[patient] i like soccer
[doctor] yeah
[patient] yeah dad dad takes me to play every saturday
[doctor] okay
[patient] it's it's pretty fun but there's this girl named isabella she she plays rough
[doctor] does she
[patient] she yeah she tries to kick me and she pulls my hair and
[doctor] oh
[patient] sometimes she's not very nice
[doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson
[patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad
[doctor] is that your favorite at mcdonald's in the the mcnuggates
[patient] not not really but they are cheap so
[doctor] okay alright well you you made dad happy at least right
[patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time
[doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens
[patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens
[doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally
[patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really
[doctor] okay good
[patient] never even though anything was going on
[doctor] okay alright good so has has karen had any seizures in the past
[patient] no
[doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching
[patient] well no uh it's just her face
[doctor] okay
[patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit
[doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome
[patient] well no history of seizures but i i i never heard of that tourette thing
[doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger
[patient] really i had nobody in our family got anything like that
[doctor] okay now tell me have you noticed any other symptoms how about like fever or chills
[patient] no
[doctor] okay coughing headache
[patient] ma'am
[doctor] okay how about any problems with karen's sleep
[patient] nope
[doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay
[patient] okay
[doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there
[patient] mm-hmm
[doctor] does that feel the same
[patient] yeah
[doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen
[patient] that's great
[doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me
[patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing
[doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards
[patient] so you're not recommending any kind of treatment there is no pill or cream or nothing
[doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay
[patient] alright alright sounds good
[doctor] alright thank you you guys have a good day
[patient] doctor
[doctor] bye karen

CLINICAL NOTE

CHIEF COMPLAINT

Right eye twitch.

SOCIAL HISTORY

The patient plays soccer every Saturday, however she has noted that there is a girl that tries to kick her and pulls her hair.

FAMILY HISTORY

Patient's father reports that they do not have a family history of seizures or Tourette's syndrome.

REVIEW OF SYSTEMS

Constitutional: Denies fever, chills, or changes in appetite.
Eyes: Reports right eye twitch. Denies right eye pain.
Respiratory: Denies cough.
Neurological: Denies headaches or sleep disturbances.

PHYSICAL EXAM

Neurological
- Orientation: Alert and oriented x3. Speech is clear and fluent. Gait is steady. Heel toe walking is normal. Cranial nerves grossly intact without focal neurologic findings. No pronator drift. Sensation is intact. Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles.

ASSESSMENT AND PLAN

1. Transient tics.
- Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic.
- Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic.
- Medical Treatment: None at this time.

Patient Agreements: The patient's parent understands and agrees with the recommended medical treatment plan. 
All questions were answered.