Generalized Tonic–Clonic Seizures

Chief Complaint
“I had a seizure a few weeks ago and banged up my head.”

HPI
Amer is a 68-year-old man whose seizures are well controlled
with carbamazepine monotherapy. The seizure from 2.5 weeks ago was the first seizure in 20
months. During the seizure, he fell to the floor and sustained a laceration to his occipital
region that required staples for closure. The description of his seizures is vague because there
have been only six seizures documented since he developed epilepsy 3 years ago. Because Mr
McNeely lives alone in an assisted living facility, only half of the documented seizures have
been witnessed by another individual who could provide a description. Two seizures were
witnessed by other residents who described him as “falling to the ground and starting to
shake.” One seizure occurred in the day room when a facility nurse was in the room, and he
documented that Mr McNeely fell to the ground, developed rhythmic extensions to both his
legs, became incontinent of urine, and was sleepy and disoriented for 2 hours after the
episode.

He has only been treated with carbamazepine. This was started by his family practice
physician after his second seizure. An EEG was obtained at that time and was unremarkable.
Because the seizures are so infrequent, the dose of carbamazepine has never been adjusted.

PMH
Tonic–clonic seizures diagnosed 3 years ago

HTN adequately controlled with lisinopril monotherapy

Dyslipidemia controlled with atorvastatin and low-cholesterol diet

BPH, currently symptom-free on dutasteride

FH
Mother died at age 74 of “natural causes”; had HTN for many years. Father died at age 70 of
“natural causes”; did not have any known medical illnesses. All his children and
grandchildren are alive and well. One son and one daughter have HTN.

SH
Retired factory worker; resides in an assisted living facility. He is widowed and has six children
and nine grandchildren, whom he sees frequently. He denies past or present tobacco and
illicit drug use. He reports a history of regular alcohol use but now only drinks one beer that
his grandson brings to him every Saturday evening.

Meds
Aspirin 81 mg PO once daily

Atorvastatin 40 mg PO once daily

Carbamazepine XR 200 mg PO twice daily

Dutasteride 0.5 mg PO once daily

Lisinopril 20 mg PO once daily

Multivitamin with minerals one tablet PO once daily

All
NKDA

Adverse drug effect history—none

Physical Examination
Gen
Exam reveals an elderly Caucasian man who appears his stated age in NAD.

VS
BP 126/78 mm Hg, HR 72, RR 16, temperature not measured; Ht 5′10″, Wt 72.5 kg
HEENT
Normocephalic; scalp: healing 3-cm lesion in the occipital region with corresponding mild
tenderness and bruising; PERRL

Neck/LN
No thyromegaly, lymphadenopathy, or carotid bruits

Chest/Lungs
Lungs CTA

CV
RRR, no m/r/g

Abd
Soft, nontender; no HSM; (+) BS

MS/Ext
Normal tone; 5/5 strength in all extremities

Neuro
Awake; A&O × 3; CN II–XII intact, reflexes 2+ and symmetric throughout

Labs
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Na 127 mEq/L Hgb 13.5 g/dL Fasting Lipid Profile
K 4.7 mEq/L Hct 41% T. chol 155 mg/dL
Cl 90 mEq/L RBC 3.9 × 106/mm3 TG 123 mg/dL
CO2 25 mEq/L WBC 5.1 × 103/mm3 HDL-C 39 mg/dL
BUN 10 mg/dL Diff WNL LDL-C 91 mg/dL
SCr 0.6 mg/dL MCV 97 μm3
Glu 100 mg/dL Carbamazepine 6 mcg/mL
EEG
Sleep-deprived EEG unremarkable. Photic stimulation failed to produce any other changes.
Assessment
1. Epilepsy with generalized tonic–clonic (GTC) seizures
2. Hyponatremia with current serum sodium level of 127 mEg/L
3. Hypertension, controlled with lisinopril 20 mg daily
4. Dyslipidemia currently treated with atorvastatin 40 mg daily
5. Benign prostatic hyperplasia currently treated with dutasteride
6. Osteoporosis with risks for fractures
Collect Information
1.
What subjective and objective information indicates the presence of generalized tonic–clonic
seizures?

Assess the Information

2.a.
Assess the severity of the generalized tonic–clonic seizure based on the subjective and
objective information available.

2.b.
Create a list of the patient’s drug therapy problems and prioritize them. Include assessment
of medication appropriateness, effectiveness, safety, and patient adherence.

Develop a Care Plan

3.a.
What are the goals of pharmacotherapy in this case?
3.b.
Create an individualized, patient-centered, team-based care plan to optimize medication
therapy for this patient’s generalized tonic–clonic seizures and other drug therapy problems.
Include specific drugs, dosage forms, doses, schedules, and durations of therapy.

3.c.
What alternatives would be appropriate if the initial care plan fails or cannot be used?
Follow-up: Monitor and Evaluate
4.a.
What clinical and laboratory parameters should be used to evaluate the therapy for
achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

Efficacy:

Adverse effects:

4.b.
Develop a plan for follow-up that includes appropriate time frames to assess progress toward
achievement of the goals of therapy.

Bonus Assignments Questions

Write a concise paper outlining the current recommendations for assisting a person who is
having a seizure.