A 13-year-old boy is brought to the office by his parents due to their concern about his behavior and academic performance. The patient is failing several classes in junior high school and has few friends. His mother reports, "His teachers complain that he doesn't pay attention and disrupts the class. One teacher says that he clears his throat repeatedly, distracting the other kids and making it difficult for her to teach. She has asked him to stop but he keeps doing it." The boy says, "I try in school but the kids are mean and make fun of me because they think I am weird or something." Over the past year, his father has observed frequent repeated blinking, which he found unusual but assumed was a sign of fatigue. His mother adds that several months ago the boy was grimacing frequently, but this seems to have passed. In the office, the boy shrugs his left shoulder repeatedly. Medical history is unremarkable. A Stanford-Binet test administered 2 years ago measured the boy's intelligence quotient as 95. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 14/min. Weight is 45 kg (99.2 lb) and height is 155 cm (5 ft 1 in). Physical examination, including neurological examination, is normal.
Which of the following is the most likely diagnosis?

Question

A 13-year-old boy is brought to the office by his parents due to their concern about his behavior and academic performance.  The patient is failing several classes in junior high school and has few friends.  His mother reports, "His teachers complain that he doesn't pay attention and disrupts the class.  One teacher says that he clears his throat repeatedly, distracting the other kids and making it difficult for her to teach.  She has asked him to stop but he keeps doing it."  The boy says, "I try in school but the kids are mean and make fun of me because they think I am weird or something."  Over the past year, his father has observed frequent repeated blinking, which he found unusual but assumed was a sign of fatigue.  His mother adds that several months ago the boy was grimacing frequently, but this seems to have passed.  In the office, the boy shrugs his left shoulder repeatedly.  Medical history is unremarkable.  A Stanford-Binet test administered 2 years ago measured the boy's intelligence quotient as 95.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Weight is 45 kg (99.2 lb) and height is 155 cm (5 ft 1 in).  Physical examination, including neurological examination, is normal. 
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c069_c3c8_8f63_21d3f956b418_MD0005_00 Tourette syndrome typically appears at age 6-15 and is more common in boys. Diagnosis requires multiple motor tics and at least one vocal tic. Both simple (eg, blinking, grimacing, shrugging) and complex motor (eg, body gyrations, odd gait, obscene gestures) tics are seen. Vocal tics can range from simple sounds (eg, coughing, grunting, throat clearing, sniffing), as in this patient, to blurting out inappropriate comments and obscenities (coprolalia). Tics are typically preceded by irresistible urges and followed by feelings of relief. They can be suppressed voluntarily for brief periods and are exacerbated by fatigue and stress. Comorbidities (eg, attention-deficit hyperactivity disorder, obsessive-compulsive disorder) are common. (Choice A) Absence seizures are very brief generalized seizures in children that cause impaired consciousness. They may occur hundreds of times a day and present as brief staring spells. (Choice B) Chronic tic disorder involves one or more motor or vocal tics (but not both) for >1 year. This patient has both motor and vocal tics. (Choice C) Tics occur in approximately 25% of normal children and typically remit spontaneously in a few weeks or months. Tics present for <1 year are diagnosed as provisional tic disorder (formerly known as transient tic disorder). This patient has multiple motor and vocal tics that are more persistent. (Choice D) Stereotypic movement disorder is characterized by repetitive and seemingly purposeless movements (eg, hand flapping, head banging). It is often associated with other neurodevelopmental disorders (eg, autism, intellectual disability, fetal alcohol syndrome). Educational objective: Tourette syndrome is characterized by simple and complex motor tics and involuntary vocalizations. A minority of individuals with the condition utters obscenities or perform obscene gestures. References: Tics and Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25150562) Clinical assessment of Tourette syndrome and tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23206664)

A 13-Year-Old Boy Is Brought to the Office by His