50/F with Focal seizures and impared awareness

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50 year old housewife  presented to our opd with the complaints of 

1 episode of loss of consciousness 3 days back 

Headache and generalised weakness 

 


She studied till her 4th grade and got married to a farmer at the age of 17 years. She gave birth to 4 children via normal vagina delivery and got operated for hysterectomy around 25 years back. Her elder son is unemployed and is an alcoholic where as the younger son is a daily wage laborer. Both of her daughters are married.  

On further questioning her brother revealed that the patients behavior has changed ever since she got married.

Her brother reveales his brother in law to be an abusive husband. He says his brother in law often beats her so much to an extent that she would often have nose bleeds. She covers her bruises and takes pain killers frequently for the pain. 

On a daily basis, both the husband and wife quarrel alot. She has become an aggressive individual herself and often bears her children. She shouts at her children and son in laws frequently. 

Her brother reveals that during arguments she has this typical behavior of pulling her hair and biting them.

He also reveals that she has been stressed lately as her elder son is unemployed and has been drinking alcohol frequently and because of frequent arguments at home he left their house in search for a job. She even isn't on good terms with both her son in laws who consume alcohol frequently and argue back with her. 

6 months back while she was working in filed she was unconscious and family members saw this and took her to tree shade and gave some fluids and took to near by hospital then she was told to have high blood pressure for which she used tablets for few days and then stopped 

15 days back her younger daughter gave birth to a baby boy and has been staying at their place ever since. Since then she has been having heated arguments with her daughter and son in law asking her daughter to change her husband's behavior and habits.


3 days back while sitting on a chair and eating a papaya and having a casual conversation with her husband, she suddenly had a loss of consciousness lasting for 5 minutes. After regaining consciousness she was given a glass of water with sugar. She herself got up and got ready to go to the hospital.


She was taken to a local hospital where in they were told that she was a hypertensive and had hypothyroid as well. 

She was given IV fluids along with Tab Telma AM and Multivitamins. 


At around 4pm at our OPD, she had another episode of loss of consciousness and micturated in her clothes after which she was rushed to casualty. At the casualty she had involuntary movements of her right upper and lower limb along with uprolling of eyes.

She was given 4 cc Inj lorazepam and she was in post ictal confusion for 1 hr

She is conscious and not answering questions though has been involving in conversations with her brother 

Her 

PR - 95 bpm

BP - 140/80

Afebrile

General examination:

Pallor absent and 

No icterus

No cyanosis ,clubbing lymphademopathy,Edema. 






Systemic examination:

Cvs apex beat in 5th ICS medial to midclavicular line 

No murmers


RS: BAE + nvbs

P/A soft ,nontender,bowels sound heard,

CNS

HMF- patient conscious 

Speech : slurred 

Memory recent and remote : Intact


Lobar function tests 

Insight +


1.Frontal:social behaviour:normal

                 language:normal

                micturation:normal

2.parietal dominant: language normal,

               ideational apraxia:present

              right left orientation: present

              finger agnosia : present

             simple : present

 complex calculations lost

             

3.parietal non dominant

              constructional skills:?

4.Temporal:

            memory and language:normal

5.occipital

          visual memory:normal

          prosopagnosia:absent



cranial nerves-1st normal


2nd Counting fingers at 6mts both eyes normal

                                             rt lf

3rd,4th,6th

                     pupil size. N N

                     DLR/CLR. N. N

NO pstosis, nystagmus.


5th sensory normal

motor normal

reflex corneal normal,conjuctival present


7th motor nasolabial fold normal

Slight deviation of mouth to right

reflex corenal and conjuctival normal +

secretomotor moistness of eye and tongue normal,buccal mucosa normal


8 the nerve:Rinnes and Weber's Normal


9and 10 th nerve: uvula centrally placed


11 th nerve: trapezieus normal sternocleidomastoid normal


12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue


MOTOR SYSTEM 

   Bulk:           Right.            Left

                        Normal.      Normal

Tone: ul. Normal. Normal

           LL. normal normal

Power UL prox 5/5. 5/5

                       distal 5/5. 5/5

                  LL.prox 5/5. 5/5

                       distal 5/5. 5/5

Reflexes.  

   Superficial reflexes

                       Right.              Left

Corneal.           Present        present

Conjunctival    Present      Present

Abdominal.     Present       Present

Plantar             mute              mute         

    Deep tendon reflexes 

                     Right.               Left

Biceps.           2+                       -        

Triceps.         2+                      2+

Supinator     -                         -

Knee              -                         -

Ankle             -                           -


 

SENSORY SYSTEM  Normal

 CEREBELLUM

Intensional tremors - absent

Pendular knee jerk - absent 

Coordination tests

      Dysdiadochokinesia absent on left side

      Finger nose test : normal

Rombergs: negative


MENINGIAL SIGNS

Neck stiffness - absent

Kernigns sign - negative

Brudzinkis sign - negative 

 Fundoscopy: Normal Fundus







Absent left internal carotid



Subclavian aretery



MRI BRAIN WITH ANGIOGRAM

Multiple infarcts in MCA and ACA territory





Absent left ICA




Severe Narrowing of left ICA


 Diagnosis : Focal seizures with global impairement secondary to ? Primary vasculitis

With k/c/of HTN and Hypothyroidism




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