55 year man with Recurrent Focal seizures

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Here is a case i have seen:

55 year old man presented to the casualty with the complaints of Unable to move his right upper limb since 9am yesterday recurrent episodes of seizures since 9 15am yesterday. Patient works as a maestri near Nalgonda. He is married to a farmer and has 3 children. His elder son works at a poultry farm, his daughter works as a teacher at a local government school and his youngest son has traumatic paraplegia since 2 years. He has been an alcoholic since 30 yrs though has been drinking more alcohol  since 4 yrs with a daily whiskey intake of around 180ml and his last intake was 5 days ago. He is an occasional beedi smoker since 35 yrs. He got diagnosed to be a diabetic 5 years back on a routine checkup after which he started using tablet metformin 500mg once daily.
 Today at 9am while he was sitting in his chair, drinking tea , he suddenly started complaining that he couldn’t move his right upper limb few minutes later he developed a sudden onset, tonic clonic seizures involving his right upper limb and lower limb lasting for 2 minutes following which he had another 8 episodes of focal  seizures involving his right upper limb and right lower limb with a 2 minutes of gap between each episode. During these episodes he had uprolling  of eyes and wasn’t followed by froth discharge from mouth or tongue bite or any involuntary micturation. He was in postictal confusion lasting for 40 minutes. He was immediately taken to a nearby hospital where he was given certain medications ( not documented) , he apparently had two more episodes of GTCS during his hospital stay. After which he was brought to our hospital. 

On presentation to us his GCS was 15, and he was drowsy His
PR was 150bpm
BP 170/90mmhg
Temp 99.8F 
Saturations at 85%
GRBS 325mg/dl
Clubbing +
CNS - bilateral pupils reacting to light
 Power           Right.            Left 
UL.                 0/5.                3/5
LL                   -4/5.               +4/5
Reflexes.       Right.            Left  
B.                       -                   2+
T.                       -                    2+  
S.                       -                    2+
K.                      2+.                 2+ 
A.                       -                     - 
Plantars - withdrawal bilaterally
Respiratory system - Bilateral inspiratory crepts in all areas, Right > Left 
CVS - muffled S1,S2
P/A - non tender          
          Soft           
          Bowel sounds +
He had to be sent to another hospital for a CT or MRI brain as it’s not working in the hospital

CT Brain:

Impression:


MRI Brain:
Impression:
EEG: 
Abnormal EEG record- suggestive of right temporal epileptogenic focus.

ECG:
    Day28/11:
Day 29/11:
Day 30/11:

Day 1/12:




Day 2/12:


Day 3/12:
Day4/12:
Day 5/12:

2D ECHO:

Seizure episodes graphical representation:

Investigations:

Day 1
At 3am he has 1episode of seizures lasting for 1minute.

Day 2
Day 3:
On day 3 he has 1 episode of focal seizures lasting for an hour.
Diagnosis:1) Recurrent Focal seizures(secondary to CVA)
2)Right hemiparesis with acute ischemic infarct in left fronto parietal area
3)Right multiple chronic infarcts 
4)Cardioembolic stroke
5)K/C/O type 2 diabetes mellitus
6)NSTEMI in Anteroseptal leads

Treatment:

Day 1: 
Oxygen supplementation@ 2-4 L/min
Inj.Levipil 1gm/IV in 100ml NS
Isosorbitate 5mg sublingual

Day 2:
Propped up posture
Oxygen  inhalation with 4 litres of oxygen( maintain spO2 >90%
Nebulisation with Duolin 6th HRLY
                               Mucomist 6th HRLY
                               Budecort 12 HRLY
Inj.Levipil 500 mg IV BD
Inj.Lorazepam 2 ml IV SOS
Inj.Thiamine 1 amp in 100ml NS /TID
Tab. Ecosprin 75 mg PO HIS
Tab.Atorvas 10 mg PO OD
Inj. Mannitol 100gm IV TID
Inj.PAN  40 mg IV OD BBF
Inj. HUMAN MIXTARD s/c
Tab.Metformin 500mg ODA
Inform SOS

Day 3:
Propped up posture
Oxygen inhalation with 4 litres of oxygen( maintain spO2 >90%
Nebulisation with Duolin 6th HRLY
                               Mucomist 6th HRLY
                               Budecort 12 HRLY
Inj.Levipil 500 mg IV BD
Inj.Lorazepam 2 ml IV SOS
Inj.Thiamine 1 amp in 100ml NS /TID
Tab.Carbamazepine 200mg PO BD
Inj.ENOXOPARIN 30 mg IV STAT followed  by Inj. ENOXAPARIN 60 mg /sc/BD
Tab. Ecosprin 75 mg PO HIS
Tab.Atorvas 10 mg PO OD
Inj. Mannitol 100gm IV TID
Inj.PAN 40 mg IV OD BBF
Inj. HUMAN MIXTARD s/c
Tab.Metformin 500mg ODA
Inform SOS

Day4:
Head end elevation
Oxygen supplementation if spO2<90%
Nebulisation with Duolin 6th HRLY
                               Mucomist 6th HRLY
                               Budecort 12 HRLY
Inj.Levipil 500 mg IV BD
Inj.Lorazepam 2 ml IV SOS
Inj.Thiamine 1 amp in 100ml NS /TID
Tab.Carbamazepine 200mg PO BD
Tab. Ecosprin 75 mg PO HIS
Tab.Atorvas 10 mg PO OD
Inj. Mannitol 100gm IV TID
Inj.PAN 40 mg IV OD BBF
Inj.ENOXAPARIN 60mg/sc/BD for 5 days
Inj. HUMAN MIXTARD s/c
Tab.Metformin 500mg ODA
Inform SOS

Day 4 soap notes:
No seizure episode since last night

PR - 72 bpm
BP- 120/80mmhg
RR- 21 Cpm
SPO2 - 92 on RA
Afebrile
Cvs - S1,S2
Lungs - inspiratory crepts in bilateral IAA, ISA region
CNS - 
Power improved comparitively 

           Right. Left 
UL. -4/5. +4/5
LL. -4/5. +4/5

P/A - soft
Non tender
Bowel sounds +

A - Focal seizures secondary to ? Right frontoparietal ischaemic infarcts
P-tab.carbamazepine with hold
  Tab.levipil 500mg bd

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