Clinic Ore Cases New Template

8/16/2019 Clinic Ore Cases New Template

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Clinical EpilepsyCase Studies

American Epilepsy Society

C Case-Slide 1


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Medical Student Cases

Case 1: 5 year-old female with episodes of“Blanking ut!

C Case-Slide 2 American Epilepsy Society 2004


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Case Study 1

" 5 y#o female is $rought to your o%ce$ecause of episodic “ $lanking out! which

$egan 1 month ago& 'he patient hasepisodes in which she a$ruptly stops allacti(ity for a$out 1) seconds* followed $y arapid return to full consciousness& 'hepatient+s eyes are open during the episodesand she remains motionless with occasional“ fum$ling! hand mo(ements&



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Case Study 1

"fter the episode the patient resumeswhate(er acti(ity she was pre(iously

engaged with no awareness that anythinghas occurred

She has ,) episodes per day

o con(ulsions



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Case Study 1

.ast medical* physical and de(elopmentalhistories are unremarka$le&

o history of pre(ious or currentmedications/ o allergies

0amily history is pertinent for her father

ha(ing similar episodes as a child&



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Case Study 1

eneral physical and neurologicale2amination is normal&

3yper(entilation in your o%ce replicates theepisodes&

C Case-Slide 6


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C Case-Slide 7

Case Study 1

EE forCaseStudy

1


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Case Study 1

4hat additional studies do you perform* ifany

4hat is the diagnosis

3ow do you initiate medication 6f so*4hich

4ould you counsel the family regardingprognosis



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Case 7: “er(ous! 8isorder



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Case Study 7

75 year-old right-handed marketing e2ecuti(efor a ma9or credit card company* $egannoticing episodes of losing track ofcon(ersations and ha(ing di%culty with ndingwords&

'hese episodes lasted 7-, minutes&

"t times* the spells seemed to $e $rought on$y a particular memory from her past&

o one at her 9o$ noticed anything a$normal&

C Case-Slide10 American Epilepsy Society 2004


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Case Study 7

.atient had no signicant past medicalhistory* and took no medicines e2cept for

the $irth control pill&

She was in psychotherapy for feelings ofdepression and an2iety* $ut was not takingmedications for mood or an2iety disorder

3er therapist notes that she has $een undersignicant stress from the $reakup with her$oyfriend&



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Case Study 7

4hat is your di;erential diagnosis at thispoint



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Case Study 7

" careful medical history re(ealed that shehad one fe$rile sei


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Case Study 7

.rior to the EE* the patient had an episodewhile on a cross country $usiness trip* inwhich she awoke on the ?oor near the$athroom of her hotel room&

She had a se(ere headache and notedsome $lood in her mouth* along with a (erysore tongue& She called the hotel physicianand was taken to the local emergency room&



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Case Study 7

4hat is your di;erential diagnosis now

• 3ow would you classify her e(ent

3ow would you e(aluate the patient in theE@ if you saw her after this episode



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Case Study 7

6n the E@* a diagnosis of nocturnalcon(ulsion was made&

" head computeri


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Case Study 7

She was gi(en fosphenytoin 1))) mg .Eintra(enously and o$ser(ed&

She was discharged home on phenytoin ,))mg per day and referred to a neurologist&

4hat would the continued e(aluation and

treatment consist of

C Case-Slide

17 American Epilepsy Society 2004


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Case Study 7

eurologist took a complete neurologic andmedical history and found patient had anuncomplicated fe$rile sei


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Case Study 7

EE showed right anterior temporal spikeand wa(e discharges&

"n M@6 of the $rain was normal&

Complaint of persistent sedation led tochange from phenytoin to lamotrigine* at a

dose starting at 5) mg B68 increasing $y 5)mg#day e(ery two weeks to reach a targetdose of ,)) mg#day&

C Case-Slide



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Case Study 7

Side e;ects were e2plained to the patient&She was also started on folic acid 1 mg per

day and was ad(ised to take a multi(itamindaily&

C Case-Slide



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Case Study 7

4hat are the most reasona$le choices ofantisei


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Case Study 7

"re there considerations regarding the oralcontracepti(e pill

4hat is the reason for the e2tra folic acid andmulti(itamin

4hat ad(ice should $e gi(en regarding lifestyle=sleep ha$its* alcohol intake> and dri(ing

C Case-Slide



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Case ,: ) yo man with his rst sei


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Case Study ,

) y#o male presents to the E@ with a historyof a single sei


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Case Study ,

6n the E@* initially the patient is weaker inthe left hand than the right side and is fullyresponsi(e and his wife feels that he hasreturned to $aseline&

.M3: on-insulin dependent dia$etes

0amily history: egati(e for sei


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Case Study ,

Current medications: ly$uride

5 mg#day

ital signs: B. 7))#1,)* 3@ 5

= regular>

@@ 1D* 'emp 1))&1

C Case-Slide



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Case Study ,

Sodium 1D1 me#A

.otassium D&7 me#A

Chloride FF me#A

Bicar$onate 7 me#A

BG H mg#dA

Cr )& mg#dA

lucose I) mg#dA

C Case-Slide

27

3ematocrit DDJ

3emoglo$in 15&D g#dA

4BC 17*)))#

H)J eutrophils

.latelets 1H)*)))

American Epilepsy Society 2004


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Case Study ,

Grine analysis: 15 4BC#3.0* nitrite positi(e

"B: p3 &,* pC7- ,I* p7- HI* 7

saturation F,J

C' scan: normal

EE: minimal $itemporal slowing

C Case-Slide



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Case Study ,

C' Scan

C Case-Slide 29



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Case Study ,

4hat work-up is needed after a single sei


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Case D: " I7 yo male with ContinuousSei


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Case Study D

" I7 y#o male without signicant pre(ioushistory of sei


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Case Study D

culocephalic re?e2 is intact&

@espirations are rapid at 77#min and

regular* heart rate is 1)5 with atemperature of 1)1&

"s you are lea(ing the room* the patient

had another sei


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Case Study D

4hat should the initial management $e

4hat initial in(estigations should $eperformed in this setting

4hat is the appropriate management withcontinued sei


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Case Study D

Aa$oratory studyresults:

CBC

4BC- 1,&1

3B 11

.lt 7))*)))

C Case-Slide

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Creatinine- 1.0

Mg 1.0

Na- 132 K- 4.5

Ca- .0

!l"cose- 0



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Case Study D

4hat are indications for lum$ar puncture in thiscase

CS0 color- clear

Cell count tu$e K 1 L 5)) @BC# ,5 4BC- 1))Jeutrophils

'u$e K , - 1)) @BC# 11 4BC

.rotein I5

lucose I)

C Case-Slide



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Case Study D

Grinalysis- => ketones

o 4hite Blood Cells or $acteria

'o2 screen: negati(e for alcohol

positi(e for $en


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Case Study D

C Case-Slide 38

#o" o$tain

an M%& o' t(e

$rain )it(

t(e 'ollo)ingimages



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C Case-Slide

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Case Study D



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Case Study D

4hich of the a$o(e studies helps to e2plainthe current sei


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Case Study D

8ene Status Epilepticus&

8escri$e the systemic manifestations of statusepilepticus&

4hat causes status epilepticus

4hat is the role of EE in status epilepticusmanagement

C Case-Slide



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Case 5: 51 year old female with freuentsei


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Case Study 5

Sei


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Case Study 5

3ow would you e(aluate and treat a patientwith a fe$rile sei


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Case Study 5

She $egan to de(elop a new type of episodein the third grade&

'he attacks consisted of her seeing a pinkelephant that was sitting on (arious o$9ectsand wa(ing to her&

'he patient has su$seuently found a

ceramic model of an elephant that was thesame as the elephant that she saw duringher sei


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Case Study 5

3ow are her symptoms di;erent from mostpatients with schi


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Case Study 5

She was not diagnosed with sei


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Case Study 5

"t age 7)* the sei


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Case Study 5

$ser(ers then note a $eha(ioral arrest&

She tends to clench her teeth and $reath

hea(ily* such that her $reathing sounds“almost as if she were laughing!&

She is una$le to fully respond to people for5-1) minutes&

'ypically* she e2periences D-5 sei


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Case Study 5

She has had se(eral EEs in the past/ themost recent a(aila$le report is from se(enyears ago* which re(ealed mild* di;useslowing of $ackground elements with noa$normalities noted during three minutes ofhyper(entilation and photic stimulation&

She had an M@6 1, years ago with no

reported a$normalities&

C Case-Slide



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Case Study 5

She has tried se(eral di;erent medications* $ut iscurrently maintained on car$ama


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Case Study 5

6n the past* she has $een unsuccessfullytried on pheno$ar$ital* primidone* (alproate*ga$apentin* phenytoin and ethosu2imide&

She had marked weight gain while taking(alproate&

She hated ha(ing sei


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Case Study 5

4hen are sei


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Case Study 5

.ast Medical 3istory:

1> Migraine headaches =with the last one

occurring four years ago>7> status-post hysterectomy with remo(al of

one o(ary 75 years ago

,> history of syndactyly at $irth with surgical

corrections/

D> partial thyroidectomy ,7 years ago duringpregnancy&

C Case-Slide



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Case Study 5

Social 3istory:

She currently li(es with her mother&

She works as a sales clerk&

She completed twel(e years of school andnished one semester of college&

She has not dri(en a car after $eing reportedto the 8M $y her doctor 7, years ago&

C Case-Slide



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Case Study 5

She tells you that she still has her dri(er+slicense&

1> 4hat are your legal and ethical o$ligations asa physician

7> 4hat are some of the employment issuese2perienced $y people with epilepsy

C Case-Slide



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Case Study 5

0amily 3istory: She has a cousin with a history of !grand

mal! sei


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Case Study 5

6mpression

• .ossi$le Mesial 'emporal Ao$e Epilepsy

• "uras of forced recall and rising autonomice2perience

• Comple2 .artial Sei


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Case Study 5

'he patient underwent (ideo-EEmonitoring&

C Case-Slide



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Case Study 5

8uring 5 days of (ideo EE* she had ,typical C.S&

3er sei


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Case Study 5

C Case-Slide

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EE! onsets

consiste* o' a

rapi* $"il* "p o'

r(yt(mic t(eta're+"ency

acti,ity o,er t(e

le't temporal

region Arro)s



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C Case-Slide

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Case Study 5

M@6 re(eals

an atrophicA&3ippocampu

s



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Case Study 5

.re-surgical E(aluation:

europsychological 'esting

• .erformance and er$al 6N normal

4ada =6ntracarotid amo$ar$ital> test

• Aanguage on Aeft side only

• o memory di;erence with left and rightin9ections

C Case-Slide



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Case Study 5

.re-surgical E(aluation: Conclusions

She has comple2 partial sei


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Case Study 5

Surgery

Surgery under local anesthesia

Aanguage map determined $y electricalstimulation

Aanguage areas =green arrow> and

epileptogenic tissue =white arrow>la$eled on ne2t slide

C Case-Slide



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C Case-Slide

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Case Study 5

M@6 showing

languageareas



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C Case-Slide

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Case Study 5

Surgery

"nterior temporal

lo$e resected

=arrow>

"mygdala and

hippocampusalso resected



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Case Study 5

0ollow-up

6mmediately following surgery she had mild

dysnomia "t three months post-op* cogniti(e testing

conrmed no change from pre-op

She has had no sei

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