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
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.

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
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

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 23

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
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.

25. 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

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