An 11 year old boy is brought to your OPD by his father.
According to him , his son gets episodes of seizures when he becomes unresponsive and is characterized by jerking movements of his right hand and legs and they may last up to 3 – 4 minutes and he becomes confused after the seizures resolve.
He gets urinary incontinence with these fits as well and tends to bite his tongue and he has to put his wallet between his teeth to prevent this.
1 . What investigations will you like to perform?
2 . What is the investigation shown in the Figure and what are its findings ?
3. What is the most likely diagnosis ?
4. What are the causes of this disease ?
5 . How will you manage this patient ?
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Answers given in comments section.
1 . What investigations will you like to perform?
Investigations
Full blood count
Check fever
Neurological examination including cranial nerves , visual fields eye movements and power in upper and lower limbs
Temperature Record
Exclude meningitis, check neck stiffness , Any history of photophobia
Monitoring of Sugar levels
Analysis of Serum Electrolytes : Sodium , Potassium , Calcium and Magnesium levels
Septic screen , exclude chest infection , urinary tract infections
Any history of head injury.
CT Brain and MRI brain if needed to exclude inracranial space occupying lesions.
EEG / Electroencephalogram
2 . What is the investigation shown in the Figure and what are its findings ?
his is a picture of MRI brain which is normal.
3. What is the most likely diagnosis ?
Grand Mal Epilepsy / Tonic clonic seizures.
A grand mal seizure ,also known as a generalized tonic-clonic seizure — is caused by abnormal electrical activity throughout the brain. Usually, a grand mal seizure is caused by epilepsy. But sometimes, this type of seizure can be triggered by other health problems, such as extremely low blood sugar, a high fever or a stroke.
Many people who have a grand mal seizure never have another one and don't need treatment. But someone who has recurrent seizures may need treatment with daily anti-seizure medications to control and prevent future grand mal seizures. Grand mal seizures have two stages:
Tonic phase. Loss of consciousness occurs, and the muscles suddenly contract and cause the person to fall down. This phase tends to last about 10 to 20 seconds.
Clonic phase. The muscles go into rhythmic contractions, alternately flexing and relaxing. Convulsions usually last one to two minutes or less.
4. What are the causes of this disease ?
Causes
Grand mal seizures occur when the electrical activity over the whole surface of the brain becomes abnormally synchronized. The brain's nerve cells normally communicate with each other by sending electrical and chemical signals across the synapses that connect the cells.
In people who have seizures, the brain's usual electrical activity is altered and many nerve cells fire at the same time. Exactly what causes the changes to occur often remains unknown.
However, grand mal seizures are sometimes caused by underlying health problems, such as:
Injury or infection
Traumatic head injuries
Infections, such as encephalitis or meningitis, or a history of such infections
Injury due to a previous lack of oxygen
Stroke
Congenital or developmental abnormalities
Blood vessel malformations in the brain
Genetic syndromes
Brain tumors
Metabolic disturbances
Very low blood levels of glucose, sodium, calcium or magnesium
Withdrawal syndromes
Using or withdrawing from drugs, including alcohol.
5 . How will you manage this patient ?
Medications
Many medications are used in the treatment of epilepsy and seizures, including:
Carbamazepine .
Phenytoin .
Valproic acid.
Oxcarbazepine.
Lamotrigine .
Gabapentin .
Topiramate (.
Phenobarbital
Zonisamide .
Finding the right medication and dosage can be challenging. Usually , first, a single drug at a relatively low dosage is sytarted, and then increase the dosage gradually until patients seizures are well-controlled.
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