1. Initial Presentation 43-year-old Caucasian male suffered a seizure 20 days ago. He also had a history of seizure 2 months before, which he did not seek medical attention. He also experience headache, nausea, weakness/numbness of the arm, and poor dental health.

2. Hx Has been diagnosed to have COPD for the past 10 years (currently uses salbutamol to ease the symptoms). Heavy nicotine addiction (70 pack/year)

3. Hx Cont’d Family history: Both parents have heart conditions and mental illnesses.

4. Hx Cont’d Social/Occupational Hx: Farmer Sedentary lifestyle Still smoking but less

5. Physical Examinations BMI: 27 BP: 123/72 mmHg HR: 88 beats/min RR: 15/min Temp: 38.2 °C

6. More examination Purulent gingival drainage and several septic teeth. Glasgow Coma Scale of 15/15 Normal PERLLA Unimpaired cranial nerves and motor-sensor functions Intact tendon reflexes

7. DDx What test should we order? What organs should we check for?

8. Smear Test Positive result of patient’s gingival smear test, indicating the presence of Staphylococcus Haemolyticus

9. Blood Test Blood test shows elevated white count, serum C-reactive protein, and procalcitonin Slightly abnormal blood clot test

10. Imaging study

11. Diagnosis ???

12. Treatment ???

13. Treatment Cont’d Surgical removal Phenytoin Antibiotics: meropenem, metronidazole, and teicoplanin

14. Follow up Patient’s condition has improved dramatically. Blood test shows no inflammation. However, he suffered from another seizure attack 2 days ago.

15. DDx What did we miss? Or was it a newly developed condition? What test should we order?

16. Bubble Test

17. Diagnosis ???

18. Treatment ???

19. Treatment Cont’d Blood thinning medication: heparin and warfarin Closure of PFO via cardiac catheterization