Patient Encounter 1 New Onset Seizures

AG, a 20-year-old male who is a college student, is seen by his physician 4 days after an apparent seizure during finals week. According to his roommate he suddenly fell to the floor and had a generalized tonic-clonic seizure. This seizure lasted for 1 to 2 minutes. The patient was incontinent for urine during the seizure. He was sleepy and confused when the paramedics arrived 10 minutes later. Due to final examinations he reports being sleep deprived.

His physical exam is completely normal and no focal neurologic deficits were observed.

What diagnostic tests should be done at this time?

Should these tests be performed prior to starting medications?

His MRI is normal, and focal epileptiform activity originating from his left temporal lobe is observed on the EEG.

Should an AED be started at this point?

If you decide to treat, what drug and dose would you use?

How should that drug be monitored?

Three months later he has another seizure, but this time it is characterized by a rising feeling in his stomach followed by confused speech, lip smacking, repetitive movements of his right hand, and unresponsiveness. This episode lasts for 2 to 3 minutes, and it takes 15 minutes for his speech to return to normal.

If he is receiving an AED, should a second AED be started at this time?

What tests and evaluations should you do before starting a second AED?

If a second drug is started, what drug and dose would you use?

If no risk factors are present, the risk of another seizure is 10% to 15%. However, if two or more risk factors are present, the risk of another seizure is 100%.

When sufficient evidence is available to determine the patient has real seizures and is at risk for another seizure, pharmacotherapy is usually started (Fig. 30-2). The patient should be in agreement with the plan, be willing to take the medication, and be able to monitor seizure frequency and adverse drug effects in some way. Design of an appropriate pharmacotherapeutic plan is based upon the patient's seizure type, the common adverse effect profile of possible AEDs, potential drug interactions, and economic factors (e.g., cost of the drug, insurance formulary, ability to pay). Other patient factors such as gender, concomitant drugs, age, and lifestyle also need to be considered.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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