Shake, Rattle, and Roll A Case of Post-Stroke Epilepsy

1. Shake, Rattle, and RollA 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

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

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

4. 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

5. 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

6. 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

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

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

9. 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

10. 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

11. 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

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

13. 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

14. Medications • Compliant with: • Aspirin 75 mg OD • Dipyridamole 200 mg/ tab OD

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

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

17. Physical Examination

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Neurologic 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

26. Salient Features

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