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

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: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