- Joined
- Oct 31, 2013
- Messages
- 301
- Reaction score
- 64
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- 4,641
Kinda long but bullet-pointed. I'd like any suggestions on this interesting fellow.
· 41 year old married male presents with irritability, sleep problems, "my whole body is tight all day."
· Denies neck, back pain but has positional numbness in arms/legs after sitting 15 minutes
· About 45 minutes after lying down will get "pins and needles" starting on thighs and radiating downward
· 7 year history of waking around midnight -2 am for 1.5 hours, then again at 4am and usually up rest of night.
· History of violent kicking and punching, carrying on full conversations in his sleep, occasional snoring, bruxism, sleep paralysis, waking with pain or crawling/aching sensations in legs.
· He describes lying in supine position, raising legs to ceiling, then slamming them down violently. Patient unaware of this but has been videoed by spouse.
· Day and night bruxism since childhood. At age 27 had full dentures rather than costly implants.
· Head injury with LOC age 6 after fall from moving vehicle. Started bed-wetting for next 7 years.
· Diagnosed with learning disorder in math, ADHD, and "severely behaviorally disordered" after head injury. Would physically attack teachers if restrained.
· Shingles age 6
· Mental and physical abuse by alcoholic father and step-mother.
· MVA age 15 which "rang my bell pretty good."
· One seizure at age 16 and one in early 20's
· MRI brain 2011-normal; MRI lower back 2014-DJD
· Relevant family history: Mother-Bipolar disorder, Schizophrenia, Grand mal seizures
· His 12-year-old son dx with ADHD by primary care and on Strattera. He has intentional tremors even when taking a break from Strattera. He describes his 4-year-old son as "a bat out of hell." He reports his 5-year-old daughter "lives in her own world and may rock for hours." She has been known to run around in circles screaming "infection." All his children have bruxism and "you can hear them down the hall." I have encouraged him to bring all in for behavioral health evals.
· Recent neuropsych testing indicated anxiety disorder, unspecified, depressive disorder, unspecified, memory problems, perfectionistic personality traits
· Patient seen by neurologist OCT 2016 who diagnosed RLS and started Mirapex 0.125mg
· Initial intake by me NOV 2016. Patient had not started Mirapex due to concerns about medications in general. Patient agreed to trial of Mirapex.
· Patient had had 3 sleep study requests, the last one a few weeks ago, and they had been denied.
· Patient diagnosed with Adjustment disorder with anxiety, REM sleep behavior disorder; Personal history of TBI, R/O RLS, R/O Nocturnal frontal lobe epilepsy.
· I really wanted PSG so submitted another request with, "due to potential for self-injury, or spousal injury, as well as considering that 50% of people with RBD tend to develop some sort of dementia-related condition, a PSG is requested."
· 2nd visit. No improvement with Mirapex. Sleep medicine consult approved! Started on Klonopin 1 mg for sleep. I am concerned that RLS-type symptoms might be due to neuropathy. Consulted his primary care PA to evaluate him carefully. PA consulted neurologist who had diagnosed RLS.
· Off post Sleep Medicine PA diagnosed patient with Hypersomnolence, Insomnia, uncontrolled, RLS, uncontrolled
· 3rd Visit. Now getting 5-7 hours of sleep with Klonopin. Repeat iron binding capacity, Ferritin, Vitamin B12, Vitamin B6, Folate, Plasma, TSH, T4, hepatic function all normal. EMG scheduled by neurologist.
· PSG indicated Sleep stage disturbance, hypersomnolence, insufficient sleep. PLM/hr normal. Patient reports neurologist (different one) told him "it was all in my head," referring to limb movements.
· Patient's one year older brother gave approval to view his PSG done several months earlier. His results were primary snoring, AHI 3.9/hr; sleep mildly fragmented; long sleep latency at 79.4 minutes; frequent PLM.
· 4th visit. Still irritable, mild anxiety & depression. Legs and arms cramping, numbness, and tingling worse and only slightly relieved by activity. Only taking 1/2 of Klonopin 1 mg as he is not a fan of medications. He agreed to swap Klonopin for Remeron 15 mg 1/2-1 tab. Mirapex 0.125 mg not helpful so increased to 2 tabs. OT consulted for cognitive-memory training.
· 5th visit. Neurological symptoms worse. Stopped Remeron after 1.5 weeks due to constipation (probably Mirapex), "didn't feel natural," and morning drowsiness. Still C/O of PLM and waking 2 am due to pain. Restarted on Klonopin 1 mg. He is concerned about back issues and since his PA refused an MRI request, I ordered one.
· EMG showed mild nonspecific axonal demyelinating peripheral neuropathy. Metabolic workup for neuropathy normal. Patient has worsening pain in lower back and from R buttock to posterior R thigh as well as pain between shoulder blades and numbness in hands. He has decreased feeling and numbness in both feet and burning in front of R thigh. Gabapentin not helpful. MRI showed degenerative changes with mild bulging disc and narrowing-referred to neurosurgery by primary care.
· 02 May patient called in complaining of severe constipation and Mirapex not helpful. Mirapex stopped and started Requip 0.5 my 1/2 tab x 2 nights, then increase to 1 tab nightly.
· Patient will be returning soon for F/U visit.
· 41 year old married male presents with irritability, sleep problems, "my whole body is tight all day."
· Denies neck, back pain but has positional numbness in arms/legs after sitting 15 minutes
· About 45 minutes after lying down will get "pins and needles" starting on thighs and radiating downward
· 7 year history of waking around midnight -2 am for 1.5 hours, then again at 4am and usually up rest of night.
· History of violent kicking and punching, carrying on full conversations in his sleep, occasional snoring, bruxism, sleep paralysis, waking with pain or crawling/aching sensations in legs.
· He describes lying in supine position, raising legs to ceiling, then slamming them down violently. Patient unaware of this but has been videoed by spouse.
· Day and night bruxism since childhood. At age 27 had full dentures rather than costly implants.
· Head injury with LOC age 6 after fall from moving vehicle. Started bed-wetting for next 7 years.
· Diagnosed with learning disorder in math, ADHD, and "severely behaviorally disordered" after head injury. Would physically attack teachers if restrained.
· Shingles age 6
· Mental and physical abuse by alcoholic father and step-mother.
· MVA age 15 which "rang my bell pretty good."
· One seizure at age 16 and one in early 20's
· MRI brain 2011-normal; MRI lower back 2014-DJD
· Relevant family history: Mother-Bipolar disorder, Schizophrenia, Grand mal seizures
· His 12-year-old son dx with ADHD by primary care and on Strattera. He has intentional tremors even when taking a break from Strattera. He describes his 4-year-old son as "a bat out of hell." He reports his 5-year-old daughter "lives in her own world and may rock for hours." She has been known to run around in circles screaming "infection." All his children have bruxism and "you can hear them down the hall." I have encouraged him to bring all in for behavioral health evals.
· Recent neuropsych testing indicated anxiety disorder, unspecified, depressive disorder, unspecified, memory problems, perfectionistic personality traits
· Patient seen by neurologist OCT 2016 who diagnosed RLS and started Mirapex 0.125mg
· Initial intake by me NOV 2016. Patient had not started Mirapex due to concerns about medications in general. Patient agreed to trial of Mirapex.
· Patient had had 3 sleep study requests, the last one a few weeks ago, and they had been denied.
· Patient diagnosed with Adjustment disorder with anxiety, REM sleep behavior disorder; Personal history of TBI, R/O RLS, R/O Nocturnal frontal lobe epilepsy.
· I really wanted PSG so submitted another request with, "due to potential for self-injury, or spousal injury, as well as considering that 50% of people with RBD tend to develop some sort of dementia-related condition, a PSG is requested."
· 2nd visit. No improvement with Mirapex. Sleep medicine consult approved! Started on Klonopin 1 mg for sleep. I am concerned that RLS-type symptoms might be due to neuropathy. Consulted his primary care PA to evaluate him carefully. PA consulted neurologist who had diagnosed RLS.
· Off post Sleep Medicine PA diagnosed patient with Hypersomnolence, Insomnia, uncontrolled, RLS, uncontrolled
· 3rd Visit. Now getting 5-7 hours of sleep with Klonopin. Repeat iron binding capacity, Ferritin, Vitamin B12, Vitamin B6, Folate, Plasma, TSH, T4, hepatic function all normal. EMG scheduled by neurologist.
· PSG indicated Sleep stage disturbance, hypersomnolence, insufficient sleep. PLM/hr normal. Patient reports neurologist (different one) told him "it was all in my head," referring to limb movements.
· Patient's one year older brother gave approval to view his PSG done several months earlier. His results were primary snoring, AHI 3.9/hr; sleep mildly fragmented; long sleep latency at 79.4 minutes; frequent PLM.
· 4th visit. Still irritable, mild anxiety & depression. Legs and arms cramping, numbness, and tingling worse and only slightly relieved by activity. Only taking 1/2 of Klonopin 1 mg as he is not a fan of medications. He agreed to swap Klonopin for Remeron 15 mg 1/2-1 tab. Mirapex 0.125 mg not helpful so increased to 2 tabs. OT consulted for cognitive-memory training.
· 5th visit. Neurological symptoms worse. Stopped Remeron after 1.5 weeks due to constipation (probably Mirapex), "didn't feel natural," and morning drowsiness. Still C/O of PLM and waking 2 am due to pain. Restarted on Klonopin 1 mg. He is concerned about back issues and since his PA refused an MRI request, I ordered one.
· EMG showed mild nonspecific axonal demyelinating peripheral neuropathy. Metabolic workup for neuropathy normal. Patient has worsening pain in lower back and from R buttock to posterior R thigh as well as pain between shoulder blades and numbness in hands. He has decreased feeling and numbness in both feet and burning in front of R thigh. Gabapentin not helpful. MRI showed degenerative changes with mild bulging disc and narrowing-referred to neurosurgery by primary care.
· 02 May patient called in complaining of severe constipation and Mirapex not helpful. Mirapex stopped and started Requip 0.5 my 1/2 tab x 2 nights, then increase to 1 tab nightly.
· Patient will be returning soon for F/U visit.
