A 71-year-old diabetic woman presented to the emergency room with sudden onset of irrelevant speech and behavior. She experienced two episodes of focal seizures involving her left side. On examination, she was disoriented with mild left-sided weakness. Tests showed elevated blood sugar and signs of inflammation. The doctors' provisional diagnoses included acute ischemic stroke, viral encephalitis, or hyperglycemic encephalopathy. She was treated with anti-seizure medications and oral hypoglycemic agents, which improved her sensorium and strength.

1. A Case of Focal Seizure with
Prolonged Disorientation
Dr.ARUL SELVAN Unit
Presenter : Dr.M.Ramesh Babu

2. Brief History
• Mrs. N 71 yrs old woman, Rt handed, house wife ,
Diabetic - 10 yrs, presented to ER with ℅
• Sudden onset irrelevant talks and behaviour & 5pm
3/2/18
• With h/o 2 episodes of left sided focal seizure
• Hematemesis - 1 episode

3. HOPI
• Patient was apparently normal till 5pm 3/2/18, started
behaving abnormally like half dressed, with carrying comb
and want to go temple, with irrelevant talks.
• Relatives observed paucity of left Upper and lower limb,
thinking of stroke - took her to near by hospital
• Asked for imaging - after imaging she developed 2
episodes of left sided jerky movements of both UL & LL
with twitching over the face - lasted for 1-2 min, treated
with sedative , Inj. insulin for high CBG - 495 mg/dl and
referred here for further management.

4. • No h/o loss of conscious during the events, no h/o tongue bite,
incontinence.
• No h/o fever, headache, neck pain
• H/o Nausea, 1 episode coffee coloured , blood stained vomiting +
• No h/o similar episodes in the past
• No significant past history - Diabetic on regular Rx, Not a
hypertensive, No CAD
• No TIA/Stroke/ loc/ fall
• No significant family history
• Personal history : takes mixed diet, appetite and sleep - N

5. On Examination
• Patient - Conscious, Markedly Disoriented,
• spontaneous eye opening +
• GCS- E4V1M4-5 ,
• Obeying commands, answers few questions
• Pupils - 3mm b/l reactive, EOM - no gaze preference,
• No Facial lag
• Speech - N

6. • Motor system - Tone - N
• Power 5/5 4-/5
• 5/5 3/5
• DTR’S - 2+
• Plantar - B/L Extensor
• Sensory sytem - N
• No cerebellar signs
• No meningeal signs
• Gait - Not tested
• CVS - No carotid bruit, S1,S2 - N
• Other systems - N

7. Provisional Diagnosis
• ?Acute ischemic stroke - left hemiparesis with focal
seizures
• ? Hyperglycemic encephalopathy
• ? Viral encephalitis

8. Investigations
• HB- 14.1gm% - 12.2
• WBC- 15990cells/cumm - 10770, -P 83%, L-9%,M-7%
• Platelets - 3.3lakhs - 2.8
• ESR- 63mm/hr
• RBS - 267 mg/dl
• CUE - N
• RFT - N
• LFT - N
• S.Na - 137, k+ - 3.9, Mg- 2.1, Ca- 9.1, Ph- 3.5, Ammonia- 0.29

9. • ECG - N
• 2DEcho- N
• U/S - Abd- Gr I Fatty liver changes

24. Final Diagnosis
• ? Acute stroke
• ? Viral Encephalitis
• ? Hyperglycemic encephalopathy

25. Treatment
• Treated with AED’S and OHA ’s
• Improved in her sensorium and power
• Now alert, well oriented
• Power 5/5 4/5
• 5/5 4+/5
• Plantar b/l flexors

26. • Thank you