CHIEF COMPLAINT: Questionable night terrors.
SUBJECTIVE: The patient is a very pleasant (XX)-year-old male who presents to the office today with mom. He is accompanied by his brother and sister. Mom notes that for the past 4 weeks, he has had night terrors. He had the same thing a few years ago.
Mom states during these episodes, he is inconsolable and actually has hallucinations with sleep walking at times. He has no recollection of the event in the morning. He had a “trigger” several years ago.
He had sore throat, which mom state was Streptococcus; although, rapid Streptococcus and culture was negative. He states he did finish antibiotics. These episodes occur about 1 per night and can last 30 minutes to 2 hours. No seizure activity is noted.
OBJECTIVE:
VITAL SIGNS: Afebrile. Pulse 96 and weight 56 pounds.
GENERAL: No apparent distress. Awake, alert, and oriented x3 male, playing on his cell phone during my entire examination essentially, which he commonly does in the room.
HEENT: Normocephalic and atraumatic. His extraocular muscle is intact. His oropharynx is clear. Moist mucous membranes. Dentition is intact.
NECK: Supple without anterior cervical or supraclavicular adenopathy. No JVD, bruits or thyromegaly.
HEART: Regular rate and rhythm without murmurs, rubs, gallops or thrills. PMI is normal.
LUNGS: Clear to auscultation. No wheezes, rales or rhonchi. Trachea is midline.
ABDOMEN: Soft, nontender and nondistended. No hepatosplenomegaly. Psychiatric: Affect is appropriate. Mood not depressed. No behavior outbursts in the room, but otherwise, he is paying attention to his cell phone.
ASSESSMENT: Night terrors.
PLAN: Certainly, it does not sound like nocturnal seizures just because these are lasting longer, occurring single in one night. Nonetheless, the only way to find out would be a polysomnography with EEG. At this point, we will have her keep a log, see if there are any triggers she can think of like caffeine or foods, and we will hold on the EEG polysomnogram unless it worsens. Mom is understanding of this. Reassurance is given.
