seizure disorder
DESCRIPTION
TRANSCRIPT
Seizure Disorder
Definition• A seizure is a paroxysmal event due to abnormal, excessive,
hypersynchronous discharges from an aggregate of CNS neurons. • Epilepsy describes a condition in which a person has recurrent
seizures due to a chronic, underlying process.
Partial seizures
Simple partial seizures
Complex partial seizures
Partial seizures with secondary generalization
Primarily generalized seizures
Absence seizures
Tonic clonic seizures
Tonic Seizureso When a tonic seizure occurs, the muscles in the body contract and
the entire body stiffenso And it often causes the person to fall down
Atonic seizureso Characterised by loss of postural tone lasting 1-2 secso Consciousness is briefly impairedo No post ictal confusion
Myoclonic seizureso Characterised by sudden and brief contraction of one part of the
body or entire body
Unclassified Seizureso Seizures that occur in neonates and infants
Status epilepticus
Vineetha Bharathan Menon
VI Pharm.D
JSSCP
SEIZURE DISORDER
Patient details:
IP no: 279411 Age: 15 years Sex: Male Weight: 53 kg Unit: Neurology I
DOA: 17/1/14
Reason for admission:
Recurrence of seizures since 2 days (5 episodes in 2 days lasting 10-20 secs).
PMx:
K/C/O: seizure disorder since 8 years (since 2010) and on regular medications (T. Phenytoin 50 mg- 0 - 50 mg, T. Clobazam 5 mg 1-0-1, recently started on T. Valproic acid 250 mg 0-0-1).
GTCS type of seizures a/w LOC for 2-3 mins
Post ictal headache (+)
No post ictal confusion
Post ictal myalgia (+)
h/o cough/ headache (+)
No h/o fever in the last week
No h/o vomiting
Developmental history:
Normal hospital vaginal delivery- normal developmental milestones achieved.
Provisional diagnosis:
Seizure disorder for evaluation
Day 1:
BP: 130/80 mmHg Pulse: 86 bpm
C/O 6 episodes of GTCS in the morning
O/E: skin lesions (+)
CNS: conscious oriented, clinically no FND
Motor System: Power 5/5, Reflexes (N)
CVS: S1S2 (+)
R/S: B/L NVBS (+), no added sounds.
ADV: Hb, TC, DC, ESR, LFT, Calcium
Treatment Chart:Drugs Dose Route Frequenc
yD1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + simethicone gel
400 mg + 20 mg in
5 ml
PO BD + + + + + +
Multivitamin 5 ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + Domperidone
40 mg + 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Laboratory Data:
Hb 14.2 gm/dl (13.5 ± 2 gm/dl)
WBC 6,900 cells/cu.mm (4000-11,000 cells/cu.mm)
PLT 2.75 lakhs/cu.mm (1.5-5 lakhs/cu.mm
ESR 5 mm/hr (0-10 mm/hr)
Hematology: Biochemistry:
Electrolytes:
Bilirubin T
0.60 mg/dl (0.1-1.0 mg/dl)
D
0.20 mg/dl (0.0-0.2 mg/dl)
Total proteins
6.5 gm/dl (6-8 gm/dl)
Albumin 3.6 gm/dl (3.4-5.0 gm/dl)
A/G ratio 1.2 (1.2-2.5)AST 35 U/L (0-40 U/L)ALT 34 U/L (0-40 U/L)ALP 277 U/L (37-306 U/L)
Ca 9.6 mg/dl (8.8-10.8 mg/dl)
Day 2:
BP: 130/80 mmHg
Case reviewed, no fresh complaints
H/o movement of hands at 4:00 am today
O/E no FND, vital stable
Rx: as per chart
Referred to dermatologist for features suggestive of adenoma sebaceum on face with ash leaf macule on chest.
Derma opinion: H/O burning sensation, lesion on nose and malar area, photosensitivity, hypopigmented patches since 7 yrs of age
Imp: Xeroderma pigmentosum
Start Suntop 30 cream (octinoxate and micronized zinc oxide lotion) and Desowen cream (desonide lotion)
Treatment Chart:
Drugs Dose Route Frequency
D1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + simethicone gel
400 mg + 20 mg in 5
ml
PO BD + + + + + +
Multivitamin 5 ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + Domperidone
40 mg + 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Day 3:
BP: 110/80 mmHg
Case reviewed, no fresh complaints
O/E no FND, vital stable
Rx: as per chart, Optho opinion
Treatment Chart:
Drugs Dose Route Frequency
D1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + Simethicone gel
400 mg+ 20 mg in
5 ml
PO BD + + + + + +
Multivitamin 5 ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + domperidone
40 mg+ 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Day 4:
BP: 110/80 mmHg
C/O 7-8 episodes of myoclonic jerks at night
CNS: no FND
CVS: NAD
Rx: as per chart
Optho opinion: c/o burning sensation and redness of eyes
Imp: NAD
Treatment Chart:
Drugs Dose Route Frequency
D1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + simethicone gel
400 mg+ 20 mg in
5 ml
PO BD + + + + + +
Multivitamin 5ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + Domperidone
40 mg + 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Day 5:
BP: 126/74 mmHg
Case reviewed, no fresh complaints
CNS, CVS: NAD
Rx: as per chart
Treatment Chart:
Drugs Dose Route Frequency
D1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + simethicone gel
400 mg + 20 mg in
5ml
PO BD + + + + + +
Multivitamin 5 ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + Domperidone
40 mg + 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Day 6:
BP: 140/80mmHg
Case reviewed, no fresh complaints
Rx: as per chart
Treatment Chart:
Drugs Dose Route Frequency
D1 D2 D3 D4 D5 D6
Valproic acid 250 mg PO 0-0-1 +
Phenytoin Sodium
100 mg PO 1-0-1 + + + + + +
Clobazam 10 mg PO 1-0-1 + + + + + +
Magaldrate + simethicone gel
400 mg+ 20 mg in
5 ml
PO BD + + + + + +
Multivitamin 5 ml PO BD + + + + + +
Protein powder 1 tsp PO BD + + + + +
Pantoprazole + Domperidone
40 mg + 10 mg
PO 1-0-0 + + + + +
Fosphenytoin 50 mg IV 1-1-1 + + +
Lamotrigine 25 mg PO 1-0-1 + + 1-0-2
+ +
Day 7:
BP: 120/80 mmHg
Case reviewed, no fresh complaints
CNS, CVS: NAD
Rx: as per chart
Adv: discharge, review after 1 week in OPD
Dishcarge medications:
Drugs Dose Route Frequency
Phenytoin Sodium 100 mg PO 1-0-1
Clobazam 10 mg PO 1-0-1
Magaldrate + simethicone gel 400 mg + 20 mg in 5 ml
PO BD
Multivitamin 5 ml PO BD
Protein powder 1 tsp PO BD
Pantoprazole + Domperidone 40 mg + 10 mg
PO 1-0-0
Lamotrigine 25 mg PO 1-0-2
Pharmaceutical Care Plan:
For seizures• Seizures since 2 days• PmHx: K/c/o seizure disorder
since 8 years
For xeroderma pigmentosum• Photosensitivity• Burning sensation and
lesion on nose and malar area
• Hypopigmentation • Irritation and redness of
eyes
For seizures• Nil
For xeroderma pigmentosum• Nil
Subjective Evidence Objective Evidence
Goals of therapy:
For seizures• To accurately diagnose the patient's seizure type and epilepsy
syndrome and determine the etiology. • To identify and eliminate patient-specific seizure precipitants. • To select optimal anticonvulsant therapy based on seizure
type, epilepsy syndrome, patient age, sex, and concomitant medical conditions. • To minimize the use of poly-drug therapy and sedating
antiepileptic drugs whenever possible.• To monitor for clinical and laboratory evidence of adverse
effects of drug therapy. • To identify and address patient concerns regarding the effect
of epilepsy and its management on daily activities, employment, and social interactions.
For XP• To protect patient from sunlight and to reduce
damaging effect of UV rays on skin
Goals achieved:
• Seizure was controlled by day 5
General treatment options
Seizure type First line agents Second line agents
Partial seizures Carbamazepine, phenytoin, lamotrigine, oxcarbazepine, valproic acid
Levetiracetam, topiramate, gabapentin, phenobarbital, primidone, felbamate
Tonic clonic seizures
Valproic acid, lamotrigine, topiramate
Zonisamide, penytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone, felbamate
Absence seizures Valproic acid, ethosuxcimide
Lamotrigine, clonazepam
Atypical seizuresAtonic siezuresMyoclonic seizures
Valproic acid, lamotrigine, topiramate
Clonazepam, felbamate
For seizures
For XP: sunscreen, vit D supplements, emollients, retinoid preparations, T4N5 lotion
Specific treatment optionsFor seizures:
GTCS: Valproic acid, lamotrigine, topiramate
Multivitamins: vit B complex, vit D & calcium supplementation
For XP: avoid exposure to sunlight, sunscreen, emollients, vit D preparations
Monitoring parameters:
• EEG• Electrolytes: Ca, Mg DISEASE SPECIFIC• Serum glucose• Neurological status
• LFTs• CBC DRUG SPECIFIC• Patients adherence to the medications
Problems identified:
• Drug interactions: valproic acid and phenytoin ( level of phenytoin)
phenytoin and lamotrigine ( level of lamotrigine)
pantoprazole and clobazam ( effect of clobazam)
• Concomitant use of magaldrate and pantoprazole• Phenytoin and clobazam not the apppropriate treatment options
for GTCS, moreover phenytoin should not be used in young patients who require long term therapy with phenytoin
• Use of protein powder• Concomitant use of phenytoin and fosphenytoin together for 3
days
Patient counseling about seizure:
Patient counseling about the common signs:
Lifestyle modifications• Care takers were informed to give stress free environment• They were advised to monitor him during sleep hours to identify seizure activity• They were asked to visit their doctor regularly• They were informed the benefits of relaxation techniques like deep breathing and meditation• They were told to provide him with healthy diet, including plenty of whole grains, fresh vegetables, and fruits• They were explained the benefit of high fat, no sugar, low protein diet• They were informed to make him wear protective clothes and avoid sun exposure as far as possible
Thank you