The medical history of this patient is already known to you. In April of this year, he first came in for therapy for the existing hemochromatosis (regular bloodletting). This has been done in 10 day rotations between April 07 and August 07, resulting in a, at this time, complete reduction of the iron concentration in the serum as well as the ferritin concentration in the blood serum (see below, lab tests are attached). This patient has been examined multiple times at the Inselspital in Bern as well as other clinics.
Due to the degree of suffering, which is relatively large, the patient himself has undertaken several endeavors and 2 years ago was diagnosed by you. Current complaints: patient describes an increase of the black outs occurring originally about a year and a half ago, as well as ‘drop attack like episodes’ and intermittent vestibular vertigo and significant cephalea. A large part of the symptoms has been recorded by the patient and is attached.
These are in particular organ specific with constant headaches, a ring like pressure feeling on the brain, migraines, washed out vision, significant concentration problems, as well as olfactory and gustatory sensations (without any indications of acute, respiratory epileptic like activity). Page 11 of original He states he has neck pain and suffers from palpations when under stress. He has a feeling of weakness in his legs as well as electricity like or ant like sensations in his legs, as well as self described erectile dysfunction and polyuria.
Furthermore, he states that he has significant reactions to food containing sugar, as well as toxins such as tobacco smoke, color and solvent odors, as well as medications such as antidepressants and Viagra, which cause him to suffer from significant headaches and ‘epileptic like’ attacks the next day. Medications: at this time none Drugs: he states he has completely stopped consuming alcohol, and used to smoke quite heavily in the past, but stopped about 2 years ago. He also states he does not use any drugs.
Social: patient lives alone, his girlfriend lives in London. He is not married and has no children. Neuro status: 32 year old, fully oriented right hander in good general condition; afebrile. Neuro psychologically his raw strength is normal. What is noticeable is his constant anxiety overlaid with fearfulness in regards to the respective health issues as well as a need to discover the causalities of his problems. Cranial nerve status: both pupils are 5 mm, and react to light and convergence. Finger perimetrically the visual fields are evocable.
The corneal reflex on both sides is significantly evocable, and funduscopically a normal finding with normal caliber retinal vessels; no degenerative abnormalities present and the pupil are both equal. No indication of nystagmus. The motoricity and sensibility of the CN V and VII is symmetrically retained, and the Barany maneuver is negative. He is able to hear finger rubbing from a distance of 10 cm. he is able to swallow normally and the gag reflex is evocable, the tongue motoricity, surface and trophism are normal. The thoracic spine as well as the nuchal muscles are not sensitive to pressure and move freely on all sides.
Neuro status: the M5 extremities move freely on both sides; the reflexes are of median liveliness, and evocable on all sides; the glabella and palmonental reflex are negative; he is sensitive to sharp, dull and touch sensitive stimuli of the extremities. The BHR is also evocable. There are no tendencies for suspension and no inversion tendencies. The diadochokinesia, KHV and FNV are normal without any errors. His gait and standing up as well as ability to walk along a line and walk blindly along a line are satisfactory. Lab test results: see attached
The patient describes diverse hyper acute occurring attacks accompanied by an almost loss of consciousness as well as absentia like conditions lasting multiple seconds, in particular after imbibing substances such as alcohol or with a lack of sleep. In 2005, a neurological consult exam utilizing an EEG was performed. At that time no epileptic like activity was noted, Due to the increase and persistence of the symptoms described by the patient over the past two years, we are requesting a neurological sleep deprivation EEG study.
The patient has been informed of this and is awaiting a reply. If one follows the extensive symptom description as offered by the patient, which is always focused on the fear of single, specific organs and organ systems, one gets the impression that a significant part of the existing symptoms point to a channeling and conversion to developing depressive symptoms. This 30 year old, previously athletic banker has for several months now been suffering from significant fatigue as well as nightly episodes of palpitations and a racing of his heart beat before falling asleep.
Additionally he has been suffering from episodes of loss of consciousness accompanied by body twitching, which tend to correspond to simple partial epilepsy, possible due to a post contusion lesion of the left frontal. Under prophylaxis of Depakine, he had no more episodes. Despite a change in nutrition, almost complete alcohol abstinence and regular sleep, he still suffers from significant fatigue. He is still able to perform well athletically. During a regular day he often experiences weakness as well as a slightly diffuse sensation of dizziness without syncope as well as evening headaches.
‘the cardiopulmonary and cursory internal status is normal, as is seen by a clinic blood pressure of 128 over 82 mmHg and the normal heart beat of 72. There are no cardiac sounds auscultable. The resting EKG is normal aside from a slight, benign, most likely vegetative caused repolarization abnormality. All cardia cavities are shown to be of normal size and the systolic and diastolic global functions are normal, with no indications of any valve or shunt defects. The cardiac stress test (bicycle) showed a normal ability to perform without any subjective or objective indications of ischemia.
The delayed heart frequency increase points to a lack of physical conditioning. The thoracic overview is normal. The long term EKG showed a normofrequent sinus rhythm with a normal frequency spectrum and multiple, nightly ventricular extra systoles. In regards to the often occurring dizziness during the day, we were not able to find a cardiac cause. An extended lab screening from 22 July 05 was completely normal and I therefore did not request further labs. He played rugby when he was younger and suffered repeated blows to the head without a loss of consciousness.
At the age of 15, in particular during the summer time, he suffered from migraines and the MRI was normal. Rest of history is bland. In the past 3 months, after a change in jobs and moving to from Genf to Zurich, he has been experiencing significant fatigue. After consuming alcohol, the next day during the hours before lunch he suffers from short attack like loss of consciousness accompanied by twitching of the entire body, at times every 5 minutes; no falls; no injuries. Due to a suspicion of a simple partial epilepsy caused by a post contusion lesion of the left frontal, we started prophylaxis with Depakine 3 x 300 mg/d.
Since then Mister McShee is free of the attacks. He also has changed his diet and has practically stopped drinking alcohol. He makes sure he gets about 7 to 8 hours of rest each night as well as regular exercise. Despite all his efforts, he still suffers from slight daytime dizziness and feelings of weakness, no syncope, but he often has slight headaches. He still experiences a general fatigue. Furthermore, he experiences directly before falling asleep a tendency for tachycardia. He does not suffer from angina pectoris or stress dyspnea. In general, his performance ability is normal.