Neuro Case

Kingdom of Saudi Arabia King Faisal University College of Medicine Department Of Neurology

Done By: Ahmed H.AL-Faraj 2051040107

History: Ali is 24 years Saudi male studying in KFUPM, single, right handed originally from Abaha living in Dhahran

CC: The patient was brought to ER in Dammam Central Hospital at 1st of February 2009 at 9.30 PM by his friend having a fit for 5 min. duration

HPI: The patient was fairly well tell 3 years back, when he at night developed dyspnea for 1/2 hr duration but no feelings of unexplained smells, visual halluisination, and distortion in visual, audiotary or time sensation. The dyspnea was followed by a seizure for about 10 min. duration, with flexion of right arm extension of left arm & lower limb , & loss of conciseness (complex partial seizure) . There was no tongue biting, self injury or loss of sphincter function (incontinence). He was brought to ER by his friend. O2 therapy in addition to injection was done for him (he can't recall what it is).When he woke up he developed dizziness & confusion for about 30 min but no headache ,aphasia, hemiparesis , or hemianopia or loss of memory. No investigation was done for him & told that the cause is stress (because it was exams time & he was not sleeping well) & referred to psychiatry clinic & discharged on medication. He did take the medication & didn't attend his appointment in psychiatry OPD. The .patient has no hx of fever, headache, vomiting or head trauma After that he gave hx of developing the same seizure 4 times per year, each was on exam times, at night (nocturnal) & in the presence of one of his friends . with no tongue biting, self injury or loss of sphincter function .The last attack was before the current one by 1 year with same presentation The current attack after severe stressful condition & was preceded by dyspnea from evening & numbness on the face. While walking downstairs he developed the seizure for 5 min with the same previous presentations (no tongue biting, incontinence, injury or salivation) . He was taken by his friend to KFUPM clinic & referred to this ER in 20 min. after waking up he complained of dizziness & desire to sleep . CT scan for brain, ECG, CXR & blood tests were done for him & .started on phyniton IV. MRI & EEG were done for him also The patient gave hx of suicidal attempt 2 years back by ingestion of 9 tablets of paracetamol. His mother is 38 years with hx of 9 years of seizure & diagnosed to have psychiatric disorder & she is on medication. He has a 23 year old .brother with Down syndrome

:Past History Medical: no history of DM , HTN or any chronic illnesses Surgical: appendectomy 2 yrs back Drugs: as mentioned above

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:Family History

Father: 54 yrs with HTN Mother:38 yrs with psychosis Siblings: 5 brothers & 5 sisters all are alive & healthy except 1 with down syndrome

:Social History Student in KUFPM in 5th year .No hx of smoking, alcohol consumption or drug abuse .No hx of smoking, alcohol consumption or drug abuse :Immunization Fully immunized

:Systemic Review :CNS & PNS

As mentioned in HPI :CVS Unremarkable

:Respiratory System

Unremarkable

:GIT

Unremarkable

:Urogenital System

Unremarkable

:Musculoskeletal System

Unremarkable

:Endocrine & metabolic symptoms

Unremarkable

:Physical Examination :General Appearance

The patient is young male lying comfortably on the bed, fully conscious, alert, & oriented to time, place & person, not in pain or respiratory distress. Well built & .nourished. Apparently not cyanosed or jaundiced

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:Vital signs .Radial pulse: 75 beats/min Blood pressure: 125 / 62 Temperature: 37.6ºC .Respiratory rate: 18/min

:Hands

Normal Nails: normal in color, no kolinechya ,no leukonychia ,no cyanosis, normal .capillary refilling , no clubbing

::Head & neck :Eyes White sclera .Normal conjunctiva :Nose Normal No discharge :Mouth Normal :Ears Normal

:Skin

Normal No lump is seen or other abnormalities are seen :Chest Bilateral equal air entry with vesicular breathing :Abdomen .Symmetrical flat soft abdomen that moves freely with respiration

:Lower limbs No deformity, LL edema & intact peripheral pulses

:CNS Examination :Mental & high cortical function .Patient is conscious, oriented to time , place & person & his memory is intact

:Language She was speaking Arabic fluently, good comprehension & repletion with no .difficulty on understanding. He can read, write & obeys command 4

:Cranial nerves :.I. olfactory n Normal smell sensation :.II.Optic n :Vision :Visual acuity in both eyes 6/7.5 :Color vision Normal :Visual field Normal :fundoscopy Normal optic disc , vessels & retina :pupils :Size . mm. rounded regular , reactive to light & accommodation 6 :Light reflex Direct: normal Indirect: normal :Accommodation Normal :.III.occulomotor,IV.trochlear & VI.abducent n Light reflex : as mentioned above Range of eye movement: normal No ptosis :V.trigeminal Sensory: light touch , temp & pain Intact bilaterally Motor: masseter , ptrygoid , temporalis Normal :Reflexes Normal jaw jerk Normal corneal reflex : VII.facial n All ms are normal No ptosis or sagging of the mouth Taste: normal :VIII.vestibulocochlear Hearing: normal Rinne's & weber's test: normal Nystagmus: none :.IV. Glossopharyngeal n. X.vagus n Normal gag reflex Normal palatal & uvula movement No difficulty in swallowing :.XI. Accessory n .Normal sternoclaidomastoid & trapezius ms :XII. Hypoglossal n Normal tongue appearance & protrude centrally

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:Upper limbs :Motor :Inspection Normal , no atrophy or fasciculation :Tone Normal :Power on right arm 5/5 on left arm 5/5 Reflexes: bilaterally ++ :Biceps ++ :Triceps ++ :Supinator ++ :Fingers Hoffman's sign : -ve

:Sensation :Light touch, temp., and vibration Normal :Sensation of joint position Normal :Stereo genesis Normal :Coordination Normal

:Lower limbs :Motor :Inspection Normal, no fasciculation, no atrophy :Tone Normal bilaterally :Power bilaterally 5/5 Reflexes: bilaterally +++ :Knee reflex ++ :Ankle reflex ++ :Hamstring ++ :Adductor Babinski : -ve

:Sensory Normal :Coordination & gait Normal

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:Impression . This a 24 years Saudi male with hx of 3 yrs of complex partial seizure

:Investigations EEG: to measure electrical activity of cortical surface neuron Brain CT scan & US: may demonstrate anatomic abnormalities Routine chemistry , blood for amino acids , urine for organic acid analysis & blood for tandem mass spectroscopy may detect metabolic disturbance MRI

:Diagnosis Cyst in the right temporal lobe

:Management Phenytoin Carbazepine Lamotrigine Gabapentine

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