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 In the ER, the patient had one episode of generalized tonic- clonic similar to similar to one she had in January. There was no urinary incontinence, nausea or vomiting. After 30 minutes, she experienced another generalized tonic- clonic seizure similar to the seizure upon arriving at the ER. She was given two doses of diazepam 5 mg/IV each episode which afforded relief.

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: Aspirin 75 mg OD 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 Neuro Exam. (ER) Awake, still confused and disoriented, able to follow some verbal commands. Primary gaze: midline disconjugate gaze, initially oscillopsia on extreme gaze. Cranial Nerves. CN II- pupils are equally reactive to light 3 mm; CN III, IV, VI- EOMs full and equal; CN V brisk corneal reflex; CN VII no asymmetry or weakness; CNXIII intact; CN IX- X (-) dysarthria, dysphagia; CN XI no weakness; CN XII tongue midline. Motor 5/5 on all extremities except for the left upper extremity 4/5. Minimal spasticity on the left. Left arm can lift 30˚. Sensory intact. Supple neck. (-) Babinski reflex. 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 Cranial Nerves: I not tested. II visual fields full to confrontation. Pupils are equally reactive to light (3 mm) and accommodation. III, IV, VI extraocular movements intact with no ptosis. V sensory- intact bilaterally in all three divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact. VII facial muscle strength intact bilaterally, sensory- taste not tested; VIII gross hearing intact. IX, X-palate and uvula elevate bilaterally, gag reflex not performed. XI- strength of sternocleidomastoid and trapezius 5/5, no observed atrophy. XII- tongue midline.

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 Sensory: Responds to pain. Temperature sensation intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity.   Motor: No muscle atrophy and normal muscle tone. 5/5 in all extremities except for the left upper extremity 4/5. Cerebellar: RAMs, finger to nose, heel along shin intact bilaterally. 25

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