Chapter Text
Note from Initial Emergency Room Visit (11/30/2024)
Provider Name: G. Collier
Patient Identifier: 90422194
Patient Name: Wilson, Wade Winston
Patient Date of Birth: 08/01/1977
Sex: Male
History of Presenting Illness
Wade Wilson presented to the ER accompanied by his roommate. Roommate reported that Wade had a seizure at home thirty minutes prior, which Mr. Wilson did not recall. Patient reported feeling “shitty” and nauseous. Roommate described increasingly bizarre behavior over the past few weeks, including speaking to people who were not present, destroying the majority of his clothes with scissors, refusing almost all food, and pacing for hours at a time. Patient reported severe difficulty sleeping and frequent nightmares.
Past Medical History
Patient is a mutant. Wade’s mutation was not apparent until several years ago, when he underwent experimental treatment for metastatic testicular cancer. Per Mr. Wilson, his mutation enables regeneration of mangled or detached body parts, as well as preventing the cancer from killing him. Patient reported that he “can’t die,” which his roommate concurred with. Patient reports no significant medical history prior to testicular cancer. Patient is not currently on any medication.
Family History
Patient was unwilling to disclose any family history. The initial question of, “Does your family have a history of seizures?” was answered with a shrug. Further questioning elicited an attempt to leave the emergency room. Roommate reported that he had no information on the patient's family.
Social History
Patient currently works as an “independent contractor” and “provisional member of the X-Men.” He lives with two roommates and a dog.
Patient reports regular use of powder cocaine by inhalation. Patient also reports regular use of alcohol. Patient denied cocaine use within the past 24 hours.
When asked about past sexual history, Mr. Wilson responded with, “The Internet is very curious about that.” Roommate reported that he was aware of past female and male partners, and that Wade had previously had several STIs.
Vital Signs
Average heart rate: 130 BPM. Tachycardia present
BP 142/93. Hypertension present
Temperature: 100 ° F
Respiratory rate: 27 breaths/minute. Hyperventilation present
SpO2: 98%
Neurologic Exam
Appearance: Patient has extensive scarring over 90% of his body. Scars appear several years old. Patient has weeping sores, approximately one inch in diameter, in multiple locations; upper right quadrant of back, left anterior forearm, right cheek, and upper left abdominal quadrant. Patient reports that these sores are recurring.
Behavior: Patient appeared anxious, and at several points attempted to leave the emergency room. Required repeated coaxing, and on one occasion threatening, by the roommate to sit down and allow examination.
Motor Activity: Repetitive motor movements present (hand-wringing), accompanied by staring into space for several seconds. Irregular twitching of the face and left arm also present
Speech: Patient alternated between speaking very fast, with a noticeable agitated tone, and being very slow to respond to questions. Noticeable slowing of speech before and after staring episodes. Sometimes trailed off mid-sentence. Repeated questions that he had already asked several minutes prior.
Mood: Mr. Wilson did not respond to my question about how he was feeling emotionally. When asked the same question by his roommate, patient responded that he was “freaking the fuck out” and would like to go home.
Affect: Affect congruent to mood
Thought Process: Intermittent thought blocking
Thought Content: Patient denied suicidal or homicidal ideation.
Perception: Patient denied hallucinating. Roommate reported that Mr. Wilson had been responding to people who were not there - likely auditory hallucination, possible visual.
Cognition: Alert. Oriented to person and situation.
Memory and Spatial Reasoning: Mini-Cog score of 2. Patient recalled two out of three words. Sunderland clock drawing score of 4. Noticeable crowding of numbers. Integrity of the number sequence is compromised: numbers are missing, illegible, or nonsensical (drawn as 10-12-13-15-16-*indiscernible*, then a large gap, then 9). Clock hands are present but not pointing at the correct time.
Insight: Poor. Repeated insistence that there was “nothing really wrong” and that he needed to go home.
Judgment: Poor. Attempted to leave ER without clothes, identification, or way of getting home.
Motor System: Myoclonus in the left arm and face
Gait, Stance, and Coordination: Stance and gait normal. Coordination on left side impaired due to muscle spasms.
Sensation: Impaired in areas of thick scarring. Otherwise normal
Assessment
Problem: Suspected NMDAR encephalitis – rapid onset of psychosis, cognitive dysfunction, seizures, abnormal speech, and movement disorder
DDx 1: Neurosyphilis– history of STIs, personality changes, memory impairment, seizures
DDx 2: Cocaine toxicity- Seizure, agitation
Plan
Admit to neurology ward, continuous EEG room. Lumbar puncture ordered. NMDA Receptor IgG Antibody with Reflex ordered. Drug screen pending. FTA-ABS pending.