Question

TONIC CLONIC SEIZURE CASE STUDY

Accompanied by his girlfriend, B.C., age 23, visits your office. His girlfriend states, "He hasn't been himself for the last month. He has headaches and is completely confused and tired for no reason." B.C. denies using illicit drugs and any recent traumatic injuries. He thinks his problem started approximately a month ago when he and his girlfriend were at a club dancing. His friends told him that he became confused and began tugging at his clothes. Then he fell down and was unconscious for a few minutes. When he awoke, he felt extremely tired and did not know what was going on. His girlfriend recalls that he had been hit in the head with a softball during a game the day before they went dancing.

Past medical history discloses insulin use since early childhood (currently 10 units NPH in the morning and 10 units regular insulin before meals), Zantac at bedtime, and Advil (1 or 2 tablets twice a day) for headaches. The patient says he has no allergies.

Family history reveals healthy parents who died in a car crash when the patient was age 10. Social history discloses a love of dancing, and active sex life, and occasional alcohol use at social events. B.C. does not smoke cigarettes or use recreational drugs.

On physical examination, B.C. is 5-foot-10 and 155 lb. His temperature is 37°C, pulse rate 78, blood pressure 118/76, and glucose level 90. Skin appears normal. Head and neck are normal, chest is clear for anterior and posterior sounds, cardiovascular RRR and (2) r/m/g, and laboratory values are within normal limits. EEG findings include sharp-wave discharges.

At a follow-up visit 2 months later, B.C. and his girlfriend report that things have gotten worse. The girlfriend states that as B.C. was eating dinner one night, he had a seizure. He was completely stiff for a short time and then his arms and legs began moving. She believes that he was unconscious for a few minutes. B.C. says he could not remember what had happened when he woke up.

1.     List the specific goals of treatment for B.C.

2.     What AED would you prescribe? Why?

3.     What are the parameters for monitoring the success of this therapy?

4.     Describe one or two drug-drug or drug-food interactions for the selected AED.

5.     Discuss specific patient education based on the prescribed therapy.

6.     List one or two adverse reactions for the selected AED that would cause you to change therapy.

7.     If the above occurred, what would be your choice for second-line therapy?

8.     What over-the-counter and/or alternative medicines might be appropriate for B.C.?

9.     What dietary and lifestyle changes would you recommend for this patient?

10.  Write a prescription for this patient.

Answer 1

1.Specific goals of the treatment

To decrease the frequency of seizure episodes.

To improve the quality of life.

To avoid all aggravating factors

2.The antiepileptic drug (AED) suitable for this patient is phenytoin.

Phenytoin is a broad spectrum antiepileptic drug that is suitable for generalised tonic clonic seizure. It will reduce the frequency of seizure attack and suppress the seizure activity. The compliance will be better.

3.Parameters to monitor the success of the treatment are number of episodes of seizure activity after starting the treatment, EEG changes after starting the treatment, ask the patient how he feels overall after taking the treatment.

4.Phenytoin inhibits the release of insulin that leads to hyperglycemia. Here, patient is already on insulin, so sometimes there may be a need to increase the dose of insulin according to the blood sugar levels. Phenytoin absorption is reduced if given along with food. So it is better to give phenytoin 2 hours after food.