Muhammad Danial Ikhwan
090424101887

11 years 9 months Malay Boy

u/L
1. Sturge Weber Syndrome type III with symptomatic epilepsy
- perinatally had ? hydrocephalus, was adviced for shunt but parents refused - no proper data
- diagnosed since 4 years old; p/w high grade fever & GTC seizure, diagnosis supported by MRA report at HKL
- previously under HKL/Putrajaya follow up, no proper data/letter
- EEG consistent with corrical malformation
- was on TCA & epilim before however stopped/defaulted TCA since 5 years ago

2. ? Stroke event in June 2013 with no neurological deficit - no proper letter; improved with physiotherapy

3. Left eye coloboma
4. Speech & development delay
5. Curtis aplasia

seizure : fit free for 4 years, then had 4 episodes of seizure in 2019, latest one in October 2020

brought to KK by stepmother; complaining of headache left temporal side throbbing in nature with sudden onset right lower limb weakness since yesterday

this morning complaining of unable to stand

had history of vomiting once 2 weeks ago, preceeded with headache which resolved post vomit

deny of trauma/fall
no fever
no URTI
no change of behaviour

Done CT brain with contrast; input from Paeds Neurologist:
Left occipital horn of lateral ventricle is especially enlarged but doesnt look that acute. Extensive angiomatosis over the left hemisphere. Risk of worsening weakness & seizures. Starting IV phenytoin maintainence for risk of seizure, together with low dose aspirin for his angiomatosis


o/e alert, concious, GCS 15/15, obeys command, pupils right side reactive 3mm, left side 5mm (cloudiness of cornea, conjunctival erythema)
BP 119/78
HR 92
SpO2 99% under room air

Neurological:
cranial nerves intact, no facial weakness
Tone normal
Power reduced over right lower limb, mainly ankle dorsiflex
Reflex increased right lower limb
Clonus absent

Plan 
MRI Spine and brain with contrast and update