Focal seizures with secondary generalization

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Here is a case i have seen:

50 year old male farmer by occupation came with chief complaints of ? GTCS type of seizures 2 episodes 2days back

He was apparently asymptomatic 6 months back.

History of present illness:

 He had ? GTCS type of seizures 1st episode on saturday morning around 1am lasting for 5 to 10 mins starting from left hand and later ?generalised with 2-3 mins of post ictal confusion 

Blurring of vision +

Uprolling of eyeballs +

Loss of consciousness +

No h/o urinary incontinence 

Aural cry +

Drooling of saliva + 

He was taken to local rmp and received some medication and was taken to home later in the evening similar episode occured around 4pm in the evening

Lasting for 5-10 mins

Aural cry+ 

Uprolling of eyeball +

No urinary incontinence 

postictal confusion +

Drooling of saliva +

Loss of consciousness +

He was taken to local physician and got treated with inj levipill 500 mg iv/bd and treated for hypokalemia (K+ - 2.6 ) syrup potchlor was advised and was referred to our hospital i/v/o better management

Patient was normal at the time of presentation 

Old episode of gtcs occured 6 months ago and had taken local medications prescribed by rmp.

Past history:

Not a k/c/o HTN,DM CAD,TB,ASTHMA 

Personal history:

 He takes mixed diet

appetite normal 

Bowel bladder movements regular

Sleep adequate

Addictions-

regular alchoholic 20 years whisky (90-180ml)

Beedi 5/day since 10-20 years

On examination

Patient is conscious,coherent,co operative

No pallor,icterus,cyanosis, clubbing, lymphadenopathy,edema

Afebrile

PR - 68/min

BP - 150/100 mmHg

RR- 16cpm

Systemic examination-

CVS -S1S2 +,no murmers

RS-bilateral air entry present,normal vesicular breath sounds heard,

P/A-soft,non tender,no organomegaly.

CNS-

Higher motor funtions normal

patient is conscious and oriented to place/time/person

Speech normal

All cranial nerves intact

MOTOR SYSTEM 

                                     Right             Left

Bulk:    inspection       Normal          Normal

             palpation.        Normal          Normal

Measurements  U/L   Equal on both sides

                          L/L   Equal on both sides

Tone:          

                         UL       Normal        Increased

                        LL      Normal         Normal

Power :

                      UL               5/5               5/5

                     LL              5/5             5/5

Reflexes -

Deep tendon reflexes

          Biceps 2+

          Triceps 2+

          Supinator 2+

          Knee 2+

          Ankle 2+

Plantars -bilateral flexor 

SENSORY SYSTEM 

                                     RIGHT.           LEFT

SPINOTHALAMIC 

             crude touch        N                 N

               pain                     N                 N

            temperature         N                 N

post:

             fine touch.        N.                   N

             vibration.          N.                   N

     position sensor.        N.                   N

 cortical 

 2 point discrimination  N.                   N

tactile localisation.        N.                   N

CEREBELLAR SIGNS -normal

Investigations-

CBP:

Hb-12.2

Tlc-6,700

Plt-2.30

Normocytic normochromic

CUE:

Specific gravity-1.010

Albumin-nil

Sugar-nil

LFT:

Tb-0.78

Db-0.20

Sgot-32

Sgpt-29

Alp-153

Total proteins-6.5

Albumin-4.0

A/G ratio-1.67

RFT:

Urea-31

Creat-1.0

Uric acid-4.8

Calcium-10.1

Phosphorus-4.1

Na-136

K -4.6

Cl-100

RBS:181

HbA1c-6.7

Serology:

Hiv - non reactive

HbSag-negative

Hcv-negative

Ecg:

Treatment given:

1.inj.levipil 500 mg iv bd

2.inj.pan 40 mg iv od

3.inj.thiamine 100mg in 100 ml NS iv od

4.inj.optineuron 1 amp in 100 ml NS iv od

5.Bp,pr,temp charting 4th hrly

6.GRBS 12th hrly

Day 2

On examination 

Patient is conscious,coherent,co operative

 Afebrile

PR - 71/min

BP - 110/80 mmHg

RR- 14cpm

No fresh complaints

Treatment given:

1.inj.levipil 500 mg iv bd

2.inj.pan 40 mg iv od

3.inj.thiamine 100mg in 100 ml NS iv od

4.inj.optineuron 1 amp in 100 ml NS iv od

5.Bp,pr,temp charting 4th hrly

6.GRBS 12th hrly

Psychiatry referral was done i/v/o alcohol dependence syndrome,they advised inj.lorazepam 4 mg IM sos(if patient is anxious and sleepless.

Day 3

On examination 

Patient is conscious,coherent,co operative

Afebrile

PR - 69/min

BP - 120/80 mmHg

RR- 17cpm

No fresh complaints

Treatment given:

1.inj.levipil 500 mg iv bd

2.tab.pan 40 mg iv od

3.inj.thiamine 100mg in 100 ml NS iv od

4.inj.optineuron 1 amp in 100 ml NS iv od

5.Bp,pr,temp charting 4th hrly

6.GRBS 12th hrly

Day 4

On examination 

Patient is conscious,coherent,co operative

Afebrile

PR - 75/min

BP - 110/80 mmHg

RR- 15cpm

No fresh complaints

Mri brain was done:

Impression-ill defined heterogenous lesion involving left frontal lobe extending into anterior portion of body of corpus callosum with evidence of patchy heterogeneous enhancement . Possibility of glioma to be considered.

Treatment at discharge:

1.tab.thiamine 100mg po od 

2 tab neurobion forte  po od

3.tab.levipil 500mg po bd

4.tab pan 40mg po od 

Pt.was referred to higher centre in view of ? Glioma management