Transcript Shake, Rattle, and Roll A Case of Post

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
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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
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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
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
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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
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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:
1) Aspirin 75 mg OD
2)Dipyridamole 200 mg/ tab OD
Family Medical History
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Diabetes
Hypertension
Breast Cancer
Stroke
Cardiovascular disease
Personal and Social History
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Married with three children
Occupation: nurse
Occasional drinker
Non- smoker
Physical Examination
Physical Examination
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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
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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
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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
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
Neurologic Examination
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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
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
Salient Features
History
Physical 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
Initial Impression
• Epileptic seizure
• R/o space- occupying lesion vs. CVD
• Hypertension Stage II
• Diabetes Mellitus Type 2