Texila American University

Case Report Format

Student Name: Dr.Shahzad Ahmad

Program/Specialization: Family Medicine

Hospital/Clinic Name: Salabiakhat Centre

Year of Study: 3rd Semester 2016

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INSTRUCTIONS
 All the fields are mandatory.
 Each field carries mark.
 Type the details in the respective columns.

EVALUATION CRITERIA
CRITERIA MARKS PROGRAM CHAIR
MARKS
Title 5
Abstract and summary 10
History 15
Examination 15
Diagnosis / Differential diagnosis 5
Investigations and interventions 10
Treatment 10
Discussion 15
Learning points 5
References 5
Communication and presentation 5
TOTAL MARKS 100

PROGRAM CHAIR COMMENTS:

PC’s SCORE
EPILEPSY OUT OF 5
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Case Report Format
ABSTRACT - PC’s SCORE
OUT OF 5

This case related to 30 years old lady, brought to us in Salabiakhat health care center
by her mother complaining of having 3 episode of seizure. Detail history and
examination was done and was diagnosed having epilepsy. patient was given
lamotrigine and she responded well and send her for follow-up.

PC’s SCORE
HISTORY OUT OF 15

Name: SARA
Age : 30

Sara 30 year old female brought by her mother to our Salabiakhat centre complaining
of her daughter behaving very odd suddenly past few days jerking and shouting and
suddenly collapse. She was unconscious with frothing from the mouth. She was
having tremor approximately for 2 min and then gain conscious. She was confusing
and she doesn’t know what happened. She cannot recall what happened to her. She
did have same thing before 1 month at work and that time also she cannot recall
what happened to her, in 3 months she has 3 episodes like this. This condition is
disturbing her life she is much stressed. No history of fever chest pain, headache of
blurring of vision.

PAST MEDICAL HISTORY

Patient does not have any chronic condition like DM, SHT, CHD, and TB.
No history of seizure in childhood or later till before 6 months.
Patient is working in a back and she was doing well.
She is not on chronic medications.
No history of any surgery in the past.
Personal History: not significant.
Menstrual history: regular cycles, no menorroghoea or dysmenorrhoea
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EXAMINATION
Height: 5.4 feet
Weight : 68kg
Bp: 110/70
Rbs: 5.2 mmol/l
RR: 17 bpm
HR: 75

On examination Patient is conscious, oriented, a febrile.

Not in distress

No pallor, icterus, cyanosis, pedal edema, cyanosis, clubbing, lymphadenopathy

CVS: S1, S2 heard. No murmurs.

PC’s SCORE OUT
Respiratory System: NVBS HEARD. No added sounds.
OF 15
Abdomen: soft, non tender, no organomegaly, no free fluid.

CNS: Higher functions: normal

Cranial nerves: normal

Tone: Normal No motor deficit.

Tendon reflexes: normal

Plantar: Bi-lateral flexor.

No cerbellar signs.

Fundus: Normal

DIAGNOSIS : PC’s SCORE

OUT OF 5
EPILEPSY
DIFFERENTIAL DIAGNOSIS
1: Cardioembolic Stroke
2: First Adult Seizure
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3: Frontal Lobe Epilepsy
4: Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes
5: Migraine Headache
6: Transient Global Amnesia

INVESTIGATIONS / INTERVENTIONS

CBC: Tc- 5100/cumm

Dc: p -65. L-35
Hb – 11.8 gms
Pcv- 35%
Platelets: 2 lakhs.

RFT
Urea: 34 mg,
Creat: 0.9 mg
Na- 137 meq/l, PC’s SCORE
K: 4 OUT OF 10
Cl: 100
Bicarb: 20meq/l

Urine routine: Albumin, sugar- nil.

Pus cells: 1 to 3 cells /hpf

EEG: Normal Study

ECG: Normal

CT: Brain normal

TREATMENT PC’s SCORE OUT

OF 10
Pharmacological treatment: Lamotrigine is the first lines started with this patient
100mg once daily in the evening and review after one week and follow up. After one
week she was advice to take 100 Mg bd. Patient tolerates well in the next visit and
advice him to follow back after one month. Patient was well after and following few
 Texila American University
Case Report Format
months she was not stressed. Having no further episodes of seizure and was advice
to continue on same dose and follow-up.

Non-Pharmalogical treatment:

A ketogenic or modified Atkins diet and vagal nerve stimulation (VNS) are no
pharmacologic methods for managing patients with seizures that are unresponsive to
antiepileptic drugs. The ketogenic diet is typically used in children. The FDA has
approved VNS stimulation for adolescents and adults with refractory partial epilepsy,
but clinical experience also suggests efficacy and safety in children and in patients
with generalized epilepsies

DICUSSION PC’s SCORE OUT

OF 15
Epilepsy is defined as a brain disorder characterized by an enduring predisposition to
generate epileptic seizures and by the neurobiologic, cognitive, psychological, and
social consequences of this condition.

Sign and symptoms:

The clinical signs and symptoms of seizures depend on the location of the epileptic
discharges in the cerebral cortex and the extent and pattern of the propagation of the
epileptic discharge in the brain. A key feature of epileptic seizures is their stereotypic nature.

Diagnosis:

The diagnosis of epileptic seizures is made by analyzing the patient's detailed clinical
history and by performing ancillary tests for confirmation. Physical examination helps
in the diagnosis of specific epileptic syndromes that cause abnormal findings, such as
dermatologic abnormalities (eg, patients with intractable generalized tonic-clonic
seizures for years are likely to have injuries requiring stitches).

The clinical diagnosis can be confirmed by abnormalities on the interictal EEG, but
these abnormalities could be present in otherwise healthy individuals, and their
absence does not exclude the diagnosis of epilepsy.

LEARNING POINTS PC’s SCORE OUT

OF 5
The goal of treatment is to achieve a seizure-free status without adverse effects.
Standard of care for a single, unprovoked seizure is avoidance of typical precipitants
(eg, alcohol, sleep deprivation). No anticonvulsants are recommended unless the
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Case Report Format

patient has risk factors for recurrence. Special situations that require treatment
include the following:

Recurrent unprovoked seizures: The mainstay of therapy is an anticonvulsant; if a

patient has had more than 1 seizure, administration of an anticonvulsant is
recommended .Having an abnormal sleep-deprived EEG that includes epileptiform
abnormalities and focal slowing, diffuse background slowing, and intermittent diffuse
intermixed slowing

Selection of an anticonvulsant medication depends on an accurate diagnosis of the

epileptic syndrome. Although some anticonvulsants (eg, lamotrigine, topiramate,
valproic acid, zonisamide) have multiple mechanisms of action, and some (eg,
phenytoin, carbamazepine, ethosuximide) have only one known mechanism of
action,

REFERENCES PC’s SCORE OUT

OF 5
1: Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy:
definitions proposed by the International League Against Epilepsy (ILAE) and the
International Bureau for Epilepsy (IBE). Epilepsia. 2005 Apr. 46(4):470-2.

2: Goodkin HP. The founding of the American Epilepsy Society: 1936-1971. Epilepsia.
2007 Jan. 48(1):15-22

3: Rho JM, Sankar R, Cavazos JE. Epilepsy: Scientific Foundations of Clinical Practice.
New York, NY: Marcel Dekker; 2004..

4: Battaglia A, Filippi T, South ST, Carey JC. Spectrum of epilepsy and

electroencephalogram patterns in Wolf-Hirschhorn syndrome: experience with 87
patients. Dev Med Child Neurol. 2009 May. 51(5):373-80

5: Hauser WA, Annegers JF, Rocca WA. Descriptive epidemiology of epilepsy:

contributions of population-based studies from Rochester, Minnesota. Mayo Clin
Proc. 1996 Jun. 71(6):576-86.

COMMUNIC ATION AND PRESENTATION PC’s SCORE

OUT OF 5
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Epileptic seizures are only one manifestation of neurologic or metabolic diseases.

Epileptic seizures have many causes, including a genetic predisposition for certain
types of seizures, head trauma, stroke, brain tumors, alcohol or drug withdrawal,
repeated episodes of metabolic insults, such as hypoglycemia, and other conditions.
Epilepsy is a medical disorder marked by recurrent, unprovoked seizures. Therefore,
repeated seizures with an identified provocation (eg, alcohol withdrawal) do not
constitute epilepsy.

As proposed by the International League Against Epilepsy (ILAE) and the International
Bureau for Epilepsy (IBE) in 2005, epilepsy is defined as a brain disorder characterized
by an enduring predisposition to generate epileptic seizures and by the neurobiologic,
cognitive, psychological, and social consequences of this condition.

Traditionally, the diagnosis of epilepsy requires the occurrence of at least 2

unprovoked seizures. Some clinicians also diagnose epilepsy when 1 unprovoked
seizure occurs in the setting of a predisposing cause, such as a focal cortical injury, or
a generalized interictal discharge occurs that suggests a persistent genetic
predisposition.