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REASON FOR REFERRAL: Facial twitching.

HISTORY OF PRESENT ILLNESS: The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximately one time per week. These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve. Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. She states that she feels fatigued all the time and does not get good sleep. She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. She thinks she may snore, but she is not sure. She does not recall any events of awakening and gasping for breath.

PAST MEDICAL HISTORY: Please see my earlier notes in chart.

FAMILY HISTORY: Please see my earlier notes in chart.

SOCIAL HISTORY: Please see my earlier notes in charts.

REVIEW OF SYSTEMS: Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.

PHYSICAL EXAMINATION:
General Examination: Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. Otherwise, general examination is unremarkable.

NEUROLOGICAL EXAMINATION: As before is nonfocal. Please see note in chart for details.

PERTINENT FINDINGS: Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. The nature of this lesion is unclear. Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.

LABS: She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.

IMPRESSION:
1. Left facial twitching-appears to be improving. Most likely, this is a peripheral nerve injury related to her abscess as previously described. In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.
2. Posterior pressure like headache, also appears to be improving. The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.
3. Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. She is on vacation next week and is going to try to see if this will help. We also discussed as before weight loss and exercise, which could be helpful.
4. Right clivus and petrous lesion of unknown etiology. We will repeat the MRI at four months to see for interval change.
5. The patient voiced understanding of these plans and will be following up with me in five months.

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