Forty year-old Software Company CEO presents to the ED because of midepigastric pain and vomiting. While waiting to have blood drawn, he loses consciousness, falls to the floor and has generalized tonic-clonic activity. He bites and macerates his tongue and urinates on himself. He remains lethargic for one hour after the episode and then becomes alert. Lab studies include - WBC 18,000 with 80% PMN; CPK - 3,000; Na 135; Blood Sugar 52; K2.1; BUN 18; bilirubin 1.8; alkaline phosphatase 200; SGOT; 100; SGPT, 97. He is admitted for further evaluation and treatment with IV fluids.

The following evening he becomes agitated, combative, confused and reports visual hallucination and is shaky and tremulous. BP is 200/110, P is 120, he is tachypneic and temperature is 38.5C. To control and restrain him, intravenous lorazepam is administrated and this makes him sleepy and vital signs normalize.

The next morning he wakens and requests help in going to the bathroom as he feels unsteady. He is confused as to the date and time of the day. Also, he reports double vision on far gaze. Exam shows confused mental state, broad based unsteady gait, nl reflexes and plantar flexor response, bilateral lateral rectus paresis and horizontal nystagmus. During the next 6 hours he becomes more lethargic and develops bilateral asterixis. One hour later he is obtunded with right hemiparesis with bilateral plantar extensor responses, fixed and dilated left pupil, impaired medial and lateral rectus paresis on the left. CT is performed and shows this lesion.

Images

1. Explain the mechanism of this patient's seizure and should have treatment been initiated after or during the fit?
   
   
2. What explains acute agitated state and why was a phenothiazine not utilized?
   
   
3. What explains the unsteady gait, diplopia, and confusion? How should that have been treated?
   
   
4. What is the explanation of the asterixis?
   
   
5. What does CT show and what is the mechanism of the neurological deterioration?
   
   
6. How should the CT lesion be treated? What laboratory studies should be performed?
   
   
7. After clinical condition is treated, he receives IV fluids and serum sodium falls from 135 to 115.  He becomes confused and has seizure. He is treated with hypertonic saline and sodium increases to 135 in 60 minutes.  Two days later he becomes dysarthric and quadriplegic.  What has happened and what brain imaging test should be done?
   

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Films C-8 (3)  Revised 6/27/2005