1. Which of the following clinical scenarios describing first onset of seizures in an adult is not responsive to medical management and requires a surgical intervention?
   
1. A 45 years old diabetic of 6 years is brought to the ER with first onset of seizures. There is history of missing his insulin doses since the past 2 days as he was travelling on official business.
2. A 70 years old man was in the hospital for his TURP. The procedure was over successfully and he was in the floors. He developed sudden onset seizures post-op on the night of surgery.
3. A 56 years old man underwent total thyroidectomy for papillary carcinoma of the thyroid. On the 5^th post operative day he developed a generalized tonic clonic seizure.
4. A 40 years old man who is otherwise in perfect health had been complaining of worsening headaches since past 2 months and he was on anti-migraine treatment. He was scheduled for a MRI of his brain and he developed a generalized seizure on the day of the MRI exam.

Answer: The first scenario is probably a non ketotic hyperosmolar seizure. The second seizure is a hyponatremic seizure following TURP (water intoxication from the irrigation fluid). The third is a hypocalcemic seizure. All the above are amenable to medical management. The last scenario is one of doubtful origin, but history is suggestive of poor response to anti-migraine treatment and worsening headaches indicative of probable tumor. The answer is (d).