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SYMPTOMATIC
EPILEPSY
Rijalun Arridho
1708436508
Supervisor:
dr. Riki Sukiandra, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD RIAU PROVINCE GENERAL
HOSPITAL
2019
Patient’s Identity
▪ Name : Mrs P
▪ Age : 93 years old
▪ Address : Pekanbaru
▪ Religion : Moslem
▪ Marital’s Status : Married
▪ Occupation : doesn’t work
▪ Admitted to Hospital : November, 11th 2019
▪ Medical Record : 7855XX
“
Chief Complaint
Cataract Hyper-
tension Paroxismal seizure
Stroke
“Change in behaviour
and lack of memory”
• Paroxismal
seizure with
Change in Currently,
postictal
behaviour and lack generalized tonic
confusion.
of memory, clonic seizure
• Patient have
Hypertension, with postictal
problem with
Stroke confusion
AED program
therapy.
Physical Examination (November, 12th 2019)
Ptosis - -
Pupil
Shape Round Round
Side Φ2mm Φ2mm Normal
Extraoculer movement Normal Normal
Pupillary reaction to light
Direct + +
Indirect + +
▪ CN IV ( Trochlearis)
Right Left Interpretation
▪ CN V (Trigeminus)
Right Left Interpretation
Normal Normal
Motoric
Difficult to Difficult to
Sensory Normal
test test
Corneal reflex
+ +
▪ CN VI (Abduscens)
Pharyngeal Arch
Difficult to Difficult to Non interpretable
Flavour sense
assess assess
Gag Reflex
▪ CN X (Vagus)
Propioseptif
Vibration Not applied Not applied -
Position (+) (+) Normal
Difficult to Difficult to
Two point discrimination Non interpretable
test test
Stereognosis (+) (+) Normal
Difficult to Difficult to
Graphestesia Non interpretable
assess assess
Reflex
Right Left Interpretation
Physiologic
Biseps (+) (+)
Physiologic reflex is
Triseps (+) (+)
Positive Normal
Patella (+) (+)
Achilles (+) (+)
Patologic (-) (-)
Babinski (-) (-)
Patologic reflex (-)
Chaddock (-) (-)
Hoffman Tromer (-) (-)
Openheim (-) (-)
Primitive Reflex
Palmomental (-) (-)
Primitive reflex (+)
Glabella (+) (+)
Snout (+) (+)
Coordination
Right Left Interpretation
Point to point movement
• Urinate : Normal
• Defecation : Normal
Other Examination
26
SIRIRAJ STROKE SCORE
Consciousness (C) : Composmentis (0)
Vomitting (V) : No (0)
Headache within 2 hours (H) : Yes (1)
Diastolic blood pressure (DBP) : 90 mmHg (90)
Atheroma (A) : Hypertension(1)
27
MMSE
SCORE 8
(Impaired
Mental status)
28
Suggestion Examination
Pharmacologic Therapy
• IVFD RL 16 dpm
• Injection Phenytoin 3 x 100 mg in Normal Saline 20 ml iv
• Injection Diazepam 10 mg prn iv
• Injection Citicolin 2 x 500 mg iv
• Amlodipin 1 x 5 mg po
Laboratory Findings
Blood routine (November, 11th 2019)
▪ Hb : 13,4 g/dL
▪ Leucocyte : 11.200 /mm3
▪ Trombocyte : 255.000/uL
▪ Hematocryte : 41 %
Laboratory Findings
Blood Glucose Profile Chemistry (November, 11th 2019)
▫ Glucose : 137 mg/dl
Electrolyte (November, 11th 2019)
▫ Na : 146 mmol/L
▫ K : 4.00 mmol/L
▫ Cl : 110 mmol/L
Imaging Study
Brain Atrophy
33
FOLLOW UP
S O A P
Headeche (+), CM, GCS 15 Symptomatic Continue therapy
seizure (-), fever (- BP : 120/80 mmHg Epilepsy ec Non Lab test for profil
November 12th ), normal speech Motoric 555/333 Haemmorrhagee lipid
2019 555/333 Stroke +
demensia
alzheimer
Headeche (-), CM, GCS 15 Symptomatic Outpatient
seizure (-), fever (- BP : 130/80 mmHg Epilepsy ec Non (phenitoin tab 3 x
), normal speech Motoric 555/444 Haemmorrhagee 100 mg, citicoline
November 13th 555/444 Stroke + tab 2 x 500 mg,
2019 Profil lipid (Toral demensia amlodipin tab 1 x
Chol 167 mg/dl, alzheimer 5 mg)
LDL 113 mg/dl,
HDL 63 mgf/dl, TG
140 mg/dl)
SYMPTOMATIC EPILEPSY EC
NON HAEMMORRHAGE STROKE
+ HYPERTENSION GRADE I +
DEMENSIA ALZHEIMER
FINAL DIAGNOSE
EPILEPSY
Epilepsy is a disease of the brain defined by any of the
following condition (ILAE official report, 2014)
1. At least two unprovoked seizure occuring > 24 h apart
2. One unprovoked seizure and probability of further seizure similar
to the general recurrence (at least 60%) after two unprovoked
seizure, occuring over the next 10 years
3. Diagnosis of an epilepsy syndrome
EPILEPSY
Epilepsy is considered to be resolved for individual who have
remained seizure-free for the last 10 years, with no seizure medicine
for the last 5 years
POST STROKE SEIZURE
39
PHYSIOLOGY
PATHOPHYSIOLOGY
CLASSIFICATION
ILAE1981 classification for the type of epileptic seizure
1. Focal/partial
Simple
Complex
Secondary generalize
2. General (Absance, mioclonic, clonic, tonic, tonic-clonic-atonic)
3. Unclassified
CLASSIFICATION
ILAE1989 classification for syndrome epilepsy
1. Focal/partial (Idiopathic, symptomatic, criptogenic) 3. Unclassified
2. General 4. Specific syndrome
Idiopathic
symptomatic
- nonspecific etiology
- spesific syndrome
- complication to another disease
criptogenic
ETIOLOGY
▪ Idiophatic
▪ Criptogenic
▪ Symptomatic
DIAGNOSE
45
THERAPY
SYMPTOMATIC
Recurrent
EPILEPSY
BASIC FINAL DIAGNOSE
50
Phamacology
• IVFD NaCl 0,9% 20 dpm is to maintain the euvolemic
condition.
• Inj Phenytoin 3 x100 mg Normal Saline 20 ml iv to
prevent any seizure
• Inj Diazepam 10 mg iv prn to manage seizure
• Amlodipine 1 x 5 mg to maintain his blood pressure
• Inj citicoline 2 x 1000 mg iv is as the neuroprotector
.
51
THANK YOU
52
53
54
Pedoman Tatalaksana Epilepsi. Kelompok Studi Epilepsi – PERDOSSI. 2012
55
1. They interfere with the ability to function independently at work or at usual activities.
2. They represent a decline from prior levels of functioning and performing.
3. They are not explained by delirium or major
psychiatric disorder.
4. Cognitive impairment is detected and diagnosed
through a combination of history-taking from the
patient and a knowledgeable informant and of an
objective cognitive assessment, either a bedside mental
status examination or neuropsychological testing.
Neuro psychological testing should be performed when
the routine history and bedside mental status examination cannot provide a confident diagnosis.
5. The cognitive or behavioral impairment involves at
least two of the following domains:
(a) Impaired ability to acquire and remember new
information – symptoms include repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, and
getting lost on a familiar route.
(b) Impaired reasoning and handling of complex tasks,
poor judgment – symptoms include poor
understanding of safety risks, inability to manage
finances, poor decision-making ability, and
inability to plan complex or sequential activities.
(c) Impaired visuo-spatial abilities – symptoms
include inability to recognize faces or common
objects or to fi nd objects in direct view despite
good acuity, and inability to operate simple implements or orient clothing to the body.
(d) Impaired language functions (speaking, reading,
writing) – symptoms include difficulty thinking of
common words while speaking, hesitations, and
speech, spelling and writing errors.
(e) Changes in personality, behavior or comportment – symptoms include impaired motivation,
initiative, increasing apathy, loss of drive, social
with drawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive
behaviors, and socially unacceptable behaviors.