Shake, Rattle, and RollA Case of Post-Stroke Epilepsy

Presenters:Timothy Joseph Abad, Anna Samantha Imperial,

Kenneth Ross JavateRose 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 OD2)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

Neurologic Examination• Neurologic– Motor

o (-) muscle, involuntary movementso 5/5 on all extremities except for left upper extremity (4/5)o Drift on the upper left extremityo DTRs: ++ on bilateral brachioradialis, biceps, triceps, patellar and ankle;

(-) Babinski– Somatic

o 100% touch/pain on all extremities. Temperature sensation intact bilaterally and symmetrically.

o Position sense intact bilaterally and symmetrically intact except for left upper extremity

– Cerebellaro No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin

intact bilaterally)– Supple neck, (-) Brudzinski, Kernig's

Salient FeaturesHistory Physical Examination

-History of left hand numbness as well as generalized tonic- clonic seizures- (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating, urinary incontinence- No memory of said events- (-) history of trauma- Known diabetic and hypertensive- Family History: Stroke, Cardiovascular disease, Hypertension, Diabetes

-Normal Physical examination -Awake, confused and disoriented, able to follow some verbal commands- GCS 14- Normal neurologic exam except for:

Motor• Minimal spasticity on the left• Left arm can lift 30˚

(+) Babinski, L- Affected positional sense in the left upper extremity

Initial Impression

• Epileptic seizure

• R/o space- occupying lesion vs. CVD

• Hypertension Stage II

• Diabetes Mellitus Type 2