The parents of a 16-year-old boy are concerned because he has been sleeping almost all day for over a month. Initially, his parents thought he had a viral infection, and he stayed home from school for several days. When his condition did not improve after a week, they took him to the doctor.
He has had some diagnostic tests, still does not have a definitive diagnosis, and continues to be unwell. He is awake for about 5 hours a day, during which time he is groggy and hungry. He eats well and uses the toilet during the time that he is awake.
He says that he feels sleepy almost all the time and wishes he did not need to sleep so much. He does not recall his dreams, including any nightmares. He has no other symptoms such as pain, stomach upset, dizziness, or fevers. He denies stress, anxiety, depression, or any issues such as bullying or upsetting events.
When he was 13 years old, a similar episode occurred during summer vacation; his condition improved by the time school started. His parents have not had similar symptoms; both are in good health.
The patient is afebrile and appears well-nourished. He seems very tired and his eyes are deep set, with the appearance of “bags under the eyes.” He is cooperative, but his eyelids shut slowly every few minutes and he seems as if he is about to fall asleep in the exam room. He is oriented and does not have aphasia or dysarthria. No involuntary movements or jerking is noted. He does not seem to be having delusions or hallucinations.
His skin appears normal. Breathing is normal and regular, and his chest is clear. Pulse is regular, with normal heart sounds. Abdomen is non-distended and is not tender.
Facial movements and sensation are normal and symmetric. His pupils are equal, round, and reactive to light, and he does not have papilledema.
Motor strength is 5/5 in bilateral upper and lower extremities, and sensation is intact to light touch, pinprick, vibration, and proprioception. Coordination is normal, without dysmetria, and he does not have ataxia. Reflexes are normal, and he can walk heel to toe without difficulty.
A urine toxicology screen does not show any substances of abuse. The results of an electroencephalogram (EEG) and a brain MRI scan are normal. A polysomnogram shows normal sleep architecture.
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