1 / 60

General Data

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

augustin-herve
Download Presentation

General Data

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. General Data • DS • 65 year old • Female • Informants: Patient and Husband • Reliability • Patient 70% • Husband 80% • Right- handed

  2. Chief Complaint • “Numbness of the left hand”

  3. 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

  4. 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

  5. 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

  6. History of Present Illness • At the ER, • Two episodes of generalized tonic- clonicseizures similar to the one in January • 30 minutes apart

  7. History of Present Illness • At the ACSU • throbbing headache located on the top of her head,(6/10) • (+) generalized weakness • (-) memory of what happened

  8. 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

  9. 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

  10. 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

  11. Past Medical History • Surgeries: None • Hospitalization: January 2010 • Allergies: No known allergies

  12. 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

  13. Medications • Compliant with: • Aspirin 75 mg OD • Dipyridamole200 mg/ tab OD

  14. Family Medical History • Diabetes • Hypertension • Breast Cancer • Stroke • Cardiovascular disease

  15. Personal and Social History • Married with three children • Occupation: nurse • Occasional drinker • Non- smoker

  16. Physical Examination

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. Physical Examination • Neurologic • Motor • (-) muscle, involuntary movements • 5/5 on all extremities except for left upper extremity (4/5) • Drift on the upper left extremity • DTRs: ++ on bilateral brachioradialis, biceps, triceps, patellar and ankle; (-) Babinski • Somatic • 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 • No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin intact bilaterally) • Supple neck, (-) Brudzinski, Kernig's

  25. Initial Impression • Epileptic seizure • R/o space- occupying lesion vs. CVD • Hypertension Stage II • Diabetes Mellitus Type 2

  26. Differential Diagnoses

  27. Syncope

  28. Transient Ischemic Attack

  29. Neoplastic

  30. Infection

  31. Stroke

  32. Hypoglycemia

  33. Subarachnoid Hemorrhage

  34. Head CT Wedge shaped I'll defined hypodense focus is seen in the cortical subcortical region of the right parietal lobe. Underlying gyrus and sulci are effaced. Patchy hypodensities along the periventricular white matter of both frontal and parietal lobes are also noted. The rest of the grey-white matter interface is maintained. Initial Imaging Studies

  35. CT Malacic changes CBC Hgb 138 Hct .42 WBC 8.5 N .72 L .24 M .04 PC 137 PT 12.2 INR 0.89 ALT 27.04 BUN 4.48 Creatinine 99.01 Na 137 K 3.9 Lipid Profile (results to follow) Initial Diagnostics

  36. Initial Management • Phenytoin • Loading dose 1gm • Maintained at 100 mg/cap TID • Admit to ACSU • Cardiac, CBG monitoring • O2 Support, seizure precautions • Diazepam 5 mg IV • Ketorolac 30 mg IV then q8 prn for headache • Continue maintenance medications

  37. Day 1 -3 (Nov 7-9)

  38. Imaging Results • Cranial MRI • Wedge-shaped Right inferior parietal cortical-subcortical encephalomalacia, gliosis and siderosis, presumably sequelae of a previous water-shed type infarction with hemorrhagic conversion • Mild microvascular white matter ischemic changes on the left centrum semiovale • Mild central cerebral volume loss

  39. Imaging Results • MRA: No aneurysm or any significant stenosis or vascular malformations seen • MRV: No evident cortical vein or dural sinus thrombosis

  40. Day 4 (Nov 10)

  41. Diagnostics • ECG: Atrial Fibrillation, RVR • TFT: • TSH 3.01 uIU/mL • FT3 2 pg/mL • FT4 0.83 ng/dL • EEG: abnormal EEG due to a focal theta slowing on the right temporo-parietal occipital region with wave epileptiform discharges on the right temporo-occipital region consistent with a focal cerebral dysfunction and a tendency toward localization-related seizures at the right temporo-occipital region

  42. Day 5-7 (Nov 11-13)

  43. Take Home Medications

  44. Case Discussion

  45. Pathophysiology Video

  46. Epileptogenesis • Transformation of a normal neuronal network into one that is chronically hyperexcitable • Trauma, stroke, or infection • Injury lowers the seizure threshold in the affected region

  47. CVD is the number one cause of epilepsy in the elderly • Oxfordshire Stroke Community Project (OSCP) • 11.5% of patients with stroke are at risk of developing late-onset post-strokeseizures within 5 years • Naess and colleagues • 10.5% developed post-stroke seizure over mean follow up of 5.7 years. • Hart and colleagues • recurrence after a first seizure after stroke of 40% in 12 months

  48. Early Onset Seizure Late Onset Seizure occurs after two weeks of stroke onset peak 6-12 months after stroke associated with the persistent changes in neuronal excitability and gliotic scarring • occurs w/in first two weeks • peak 24 hrs after stroke

  49. Stroke severity Independently associated with the development of seizures after ischemic stroke (HR, 10; 95% CI, 1.16 to 3.82; P<0.02) Seizures and Epilepsy After Ischemic Stroke OsvaldoCamilo and Larry B. Goldstein, 2004 • Cortical location • Best-characterized risk factor for early seizures after ischemic stroke • Significant risk factor in the SASS study (HR, 2.09; 95% CI, 1.19 to 3.68; P<0. 01)

  50. Management • Antiepileptic Drug Therapy • Goal: completely prevent seizures without causing untoward side effects • Treat the underlying conditions • Reverse the problem and prevent its recurrence

More Related