Presenter: Tyler Reimschisel, MD Preceptor: Harvey Singer, MD

Disclosures

October 07, 2002

General Physical Examination

On physical examination, head circumference was normal for a 2-month-old. He had sparse hair. His cheeks were round and rosy and he had no dysmorphic facial features. No abnormalities were found during chest, lung, and cardiac evaluations, and he had no hepatomegaly.

Mental status: No abnormalities are noted on the documentation provided.

Cranial nerves: The baby's pupils reacted briskly to light, and a red reflex was visualized bilaterally. Extraocular movements were conjugate and full. Facial movements were symmetric; hearing was intact based on a bedside evaluation. His palate elevated symmetrically and his tongue was at midline.

Motor: Bulk was normal for age. The patient had diffuse hypotonia. He moved all his extremities symmetrically but had complete head lag when pulled to sit. He had occasional myoclonic jerks of his extremities. In general, he displayed the motor skills of a newborn.

Deep tendon reflexes: 2/4 throughout.

An EEG at this time demonstrated epileptiform discharges that correlated with the patient's myoclonic jerks. He had no other clinical or electrographic seizure activity. A repeat brain MRI performed approximately 6 weeks after the first MRI revealed bilateral basal ganglia strokes and a left occipital lobe stroke.

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