1. 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

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: 1) Aspirin 75 mg OD 2)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. Awake, not in cardiorespiratory distress Height: 165 cm Weight: 80 kg BMI = 34 BP = 160/70 HR = 73 RR = 14 T = 36.5 O C

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 5 th 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 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. o 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

26. Salient Features HistoryPhysical 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

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