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A 38 year old hairdresser and mother presented to the ER seven hours after having
a witnessed grand mal seizure. She had no warning and only remembered talking
to her daughter. The next thing she remembered was waking up in the ambulance
unable to move her right side. She also noted trouble understanding what was being
said to her. She had an unremarkable review of systems. Her past medical history
was positive for a benign cyst removal from the left breast and the removal of
a left arm skin mole 4 years previously. The mole was found to have microscopic
foci of melanoma, but the margins were clear. In the Emergency Room, she was found
to have a blood pressure of 210/110 and a pulse of 70. Her general physical examination
was normal. She was obtunded and weak in both the right arma and leg. There was
mild lower right facial weakness. Her daughter said these changes were all new.
Her sensory examination showed dminished appreciation of two poit discrimination,
graphesthesia and baresthesia on the right. She appeared to have a fluent aphasia
with difficulties in comprehension and repetition.There was a right Babinski sign.
Her initial laboratory work was normal.
Her chest X-ray was normal. A CT done in the ER demonstrated a well-encapsulated
left frontal lobe hemmorhage. An EEG was done withing a few hours of her admission
to the ER and showed left sided slowing with periodic sharp wave activity.
Questions:
- What is a Todd's paralysis? How could you differentiate it from a hemiparesis
due to the hemmorhage in this case?
- What is the differential diagnosis of the seizure in this patient? What
tests would you do to establish the correct diagnosis?
- The EEG showed focal activity and the CT showed a focal lesion, yet the
patient had a generalized (grand mal) seizure. What is the mechanism by
which focal lesions produce generalized convulsions?
- The patient was admitted to the Neurology Ward Service. You are making
rounds the next morning and the patient complains of jerking of her right arm.
Observing her, you see jerky, seizure-like movements of the right arm and forearm,
yet the patient is alert and aware of the movements. They are continuous. An EEG
continues to show the left sided slowing with periodic sharp wave activity. What
is this symptom called and how should it be treated?
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