### a 50 years old married woman was admitted to nemcare superspeciality

### A 50 years old married woman was admitted to Nemcare Superspeciality Hospital, Guwahati (Assam) with the complaint of convulsions since 1 month. At the outset, the episodes of convulsions were for 10-15 mins which persisted for 20 days. From last 7 days, the episodes were for 1.5 hours and occurs daily, sometimes even twice a day. Medicines were prescribed but seizure episodes were not under control according to the patient's family members. There is no similar history of such convulsions before 1 month. No similar history among other family members. This is the first time she developed such convulsions in her 50 years of age. The episodes are preceded by an aura (the patient herself says that she is having some headache or other disturbance and asks someone to prepare the bed so that she can lie down on the bed and becomes unconscious). There's no history of frothing from mouth, no abnormal jerky movements, no pulling of extremities towards herself but she clenches her teeth while she is unconscious. She couldn't remember also as what happened after the aura. She is normotensive. Though CT scan is a must in this case but it has not been seen to be done. Other reports like ECG, Echocardiogram, Chest X Ray, Creatinine, RBS and USG W/A have been attached. Her TSH is high for which she has been prescribed Tab. Thyronorm 25 mcg (Thyroxine) : Once daily after breakfast to continue. Other medications for the convulsions have been shown in the prescription though patient got no relief from them. Kindly have a look at the case and the reports and please give your valuable opinions regarding the further management of this case. Thanking you in anticipation. Regards, Dr. Mohammad Shofique, Medical Officer (Agia Hospital), Guwahati, Assam, Mobile Number: 9435570295

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First of all my doubt is that It's a case of clear-cut malingering i believe.So take Family History with attendants and take her personal history.Does she has any personal issues.Coz no LOC,no froathing no involuntary Urine or bowl and aura and that too she asking for bed arrangement,No HTC and she gets up after some time and not improved with any medicine.Though above said may not be there in all seizures but it looks like so.If she is not showing any improvement with Medicines then Sedate her Consult with Psych doc too

Exactly sir . I completely agree with you.
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Dear doctor,,, pt now probably is controlled,,, but she had status epilepticus,,,, so she has to have urgent CT brain to R/o IOL,, for treatment 1. Airway mx, start oxygen if unconscious. 2.laoding dose of phenytoin 15mg/kg to 20mg/kg b wt. Over 1/2hr in no, Then continue with infusion. 3. Give IV midazolam 3mg stat or diazepam 0.2mg/kg at 5mg per min or lorazepam 0.1mg/kg at rate 2mg/min 4. Call anaesthetist for further management, can gv thiopentone iv, Rest treatment as per the diagnosis,

Thorough history needed. About onset and nature of seizures and any history of trauma. Looks like late onset epilepsy presenting as complex partial seizures which could be due to number of reasons. Rule out Dyselectrolytemia, Need CT and neuro opinion to rule out Head trauma,Cerebrovascular Stroke Need T3 T4 values to comment on thyroid state. Any tumour involving pituitary can lead to high TSH. If that's the case,prescribing more thyroxine can actually worsen the state which can present as more anxiety and seizure like symptoms. If all these are ruled out then it might be dementia,Alzheimers or psychosis/anxiety disorder. Need electrolyte panel and CT/MRI just to start :

All the reports r WNL except HYPOTHYROID 2nd thing C.T must My two dd 1) Migraine 2)some psychological issue

Dr shofique Please chek all metabolic parameters Contrast CT Scan brain U can have video recording of seizure episodes Till than treat as case of CPS

I agree with Dr R J P Reddy

For your information ELTROXIN SHOULD BE GIVEN ON EMPTY STOMACH.

I agree with Dr. R. Jaya prakash Reddy

Exclude organic cause before labelling malignering CT must
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Convulsions/Seizure never alarm you to make a bed or time or family attention.

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