NYU Medical Grand Rounds Clinical Vignette

Megha Shah

PGY-2

November 10, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

The patient is a 45 year old man who presented with a three month history of repeated loss of consciousness, accompanied by bilateral upper extremity jerking.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient’s medical history began when he was a child in China, when he reports the onset of a seizure disorder.

•As a child, he had been on antiepileptic medications, with complete resolution of his seizures just prior to starting high school.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•He was in his usual state of health until 20 years prior to admission when his seizures recurred. He was restarted on his antiepileptic medications at that time.

•In 2008, the patient moved to the United States, at which time his seizures increased in frequency to approximately twice a week.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•He was seen by an outside physician and his medications were adjusted.

•He was doing well clinically until three months prior to admission, when his seizures again increased in frequency to twice daily.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Three days prior to admission, the patient had a seizure that lasted approximately three minutes, during which he lost consciousness, had bilateral upper extremity jerking, and a confused state after the seizure.

•He was then admitted to New York University Langone Medical Center for further evaluation of his seizures.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History•Past Medical History:

• None•Past Surgical History:

• None•Social History:

•Denies any alcohol, tobacco, or illicit drug use•Currently unemployed•Married with one adult son

•Family History:•No known history of epilepsy

•Allergies: •No known drug allergies

•Medications:•Carbamazepine 400mg twice a day•Valproic acid 500mg twice a day•Lacosamide 50mg twice a day•Multivitamin 1 tablet once a day

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical ExaminationGeneral: Alert and oriented to person, place, and time, in no acute distress. Appeared stated age and answered questions appropriately

Vital signs: T: 99.0 BP: 138/94 HR: 99 RR: 20

O2 sat: 99% on room air

Neurological exam: cranial nerves II-XII grossly intact, 5/5 strength in all extremities, sensory intact. 2/2 reflexes ankles, knees, biceps, triceps, and toe flexors. Negative Romberg

Remainder of physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•Basic metabolic panel: within normal limits

•CBC: within normal limits

•Hepatic panel: within normal limits

•Carbamazepine level: 7.4 (normal 8-12)

•Valproic acid level: 47.7 (normal 50-100)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Working Diagnosis

•Refractory epilepsy

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– Antiepileptic medications were held in a progressive

manner to provoke seizures, in order to capture them on video electroencephalogram recording.

– Lacosamide was held first

• Hospital Day 2:– Valproaic acid was decreased to 250mg once daily– The patient had two seizures, both with right eye

deviation with head turning, and left arm extension.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 3-5:

- Carbamazepine and valproic acid were held

- The patient had an additional 4 seizures, similar to those he had previously

• Day of discharge:

- All medications were restarted, and the patient was without complaints.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•Video Electroencephalogram:

Cortical hyperexcitability in the right

frontotemporal regions consistent with an epileptic focus in the frontotemporal lobe.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• At this time, the patient is currently undergoing preoperative evaluation for possible temporal lobe resection.

Interim History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Refractory temporal lobe epilepsy

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS