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Shake, Rattle, and Roll A Case of Post-Stroke Epilepsy Presenters: Timothy Joseph Abad, Anna Samantha Imperial, Kenneth Ross Javate Rose Ann Palma, Raymonde Charles Uy, Ma. Regina Paula Valencia General Data • • • • • DS 65 year old Female Informants: Patient and Husband Reliability – Patient 70% – Husband 80% • Right- handed Chief Complaint • “Numbness of the left hand” History of Present Illness • Nine months PTA, – “pins and needles” sensation; left hand – one episode of generalized tonic- clonic seizure • • • • • Head tilting to the right Eyes rolling upward Stiffening of upper and lower extremities Tongue biting Lasting for 1- 2 minutes – (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating, urinary incontinence History of Present Illness • Admitted in the hospital for 10 days – CT scan was done – Discharge summary: Seizure. Two old right parietal lobe hemorrhagic infarcts. Hypertension. Diabetes Mellitus Type II. Hypercholesterolemia. – Medications prescribed: • Aspirin 75 mg OD • Dipyridamole 200 mg OD • Perindopril 8 mg OD – No memory of what happened – Patient was able to go back to work History of Present Illness • One hour PTA, – (+) inward movement and numbness of the left hand – (+) disorientation and confusion – (+) stiffness of truncal extremity – (+) rapid and incoherent speech History of Present Illness • At the ER, – Two episodes of generalized tonic- clonic seizures similar to the one in January • 30 minutes apart History of Present Illness • At the ACSU – throbbing headache located on the top of her head,(6/10) – (+) generalized weakness – (-) memory of what happened Review of Systems • • • • • • Neurologic: (-) history of gait imbalance, frequent headaches General: (-) fever, weight loss, easy fatigability HEENT: (-) tinnitus, colds, epistaxis, otorrhea Respiratory: (-) difficulty of breathing, coughing Cardiovascular: (-) chest pains, orthopnea, PND Gastrointestinal: (-) change in bowel movements, abdominal pain, melena, hematochezia Review of Systems • Genitourinary: (-) dysuria, frequency, incontinence, tea colored urine • Endocrine: (-) heat or cold intolerance, excess thirst, excess sweat, polydipsia, polyuria • Musculoskeletal: (-) joint pain and swelling • Dermatologic: (+) dermatoses/ trophic skin changes Past Medical History • Illnesses – Angina 2007 maintained on ISMN (Imdur) 60 mg tab OD – Hypertension maintained on Bisoprolol 10 mg OD and Perindopril 8 mg OD – DM Type II 2000 maintained on Insulin glargine (Lantus) 40 mg SQ OD – Hypercholesterolemia 2000 maintained on Atorvastatin 20 mg/ tab OD • (-) Trauma • (-) History of febrile seizures Past Medical History • Surgeries: None • Hospitalization: January 2010 • Allergies: No known allergies Past Medical History • Ob- gyne – G3P3(3003) – LMP 55 years old – (+) OCP use for 6 months; 1981 (36 yo) – (-) hormone replacement therapy – (+) preeclampsia: third pregnancy – (+) blood transfusion: third pregnancy Medications • Compliant with: 1) Aspirin 75 mg OD 2)Dipyridamole 200 mg/ tab OD Family Medical History • • • • • Diabetes Hypertension Breast Cancer Stroke Cardiovascular disease Personal and Social History • • • • Married with three children Occupation: nurse Occasional drinker Non- smoker Physical Examination Physical Examination • • • • • • • • Awake, not in cardiorespiratory distress Height: 165 cm Weight: 80 kg BMI = 34 BP = 160/70 HR = 73 RR = 14 T = 36.5OC Physical Examination • HEENT – Anicteric sclerae; pink palpebral conjunctiva – No nasal congestion – Moist buccal mucosa – (-) cervical lymphadenopathy, tonsillopharyngeal congestion, enlarged thyroid gland – non- distended neck veins, (-) carotid bruit • Respiratory – Symmetric chest expansion – No retractions – Clear breath sounds Physical Examination • Cardiovascular – Adynamic precordium – Apex beat at 5th ICS LMCL – Regular rhythm, normal rate – Distinct S1 at apex and S2 at base – (-) Murmurs • Abdominal – Flabby, soft abdomen – Normoactive bowel sounds – No tenderness – No organomegaly Physical Examination • Extremities – Full and equal pulses (2+) – (-) edema – Good skin turgor • Skin – Normal hair and scalp, nails – Trophic skin changes/ dermatoses – No pallor or jaundice Physical Examination • Neuro examination at the ER: – Awake, confused and disoriented, able to follow some verbal commands; GCS 14 – Intact cranial nerves – Intact sensory – Motor • Minimal spasticity on the left. • Left arm can lift 30˚. – Supple neck – (+) Babinski reflex, L Neurologic Examination • GCS 15 • Mental Status Exam: – Cooperative towards examiner – Awake, alert with intact attention span – Euthymic with appropriate affect – Non- spontaneous, normoproductive speech – No perceptual disturbances – Goal oriented with normal thought content – Oriented to time, place and person – Intact memory and calculation – Good fund of information – Good insight and judgment – (-) agnosia, apraxia Neurologic Examination – Cranial Nerves • I – Not done • II – Pupils 3mm, equally reactive to light; visual fields full to confrontation • III, IV, VI – Full EOM’s • V – Corneal reflex not done, sensory- intact bilaterally in all three divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact • VII – No facial weakness and asymmetry • VIII – Gross hearing intact • IX, X – (+) gag reflex • XI- (+) shoulder shrug, head turn, 5/5 • XII – tongue at midline Physical Examination • Neurologic – Motor o (-) muscle, involuntary movements o 5/5 on all extremities except for left upper extremity (4/5) o Drift on the upper left extremity o DTRs: ++ on bilateral brachioradialis, biceps, triceps, patellar and ankle; (-) Babinski – Somatic o 100% touch/pain on all extremities. Temperature sensation intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity – Cerebellar o No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin intact bilaterally) – Supple neck, (-) Brudzinski, Kernig's Initial Impression • Epileptic seizure • R/o space- occupying lesion vs. CVD • Hypertension Stage II • Diabetes Mellitus Type 2