Answer questions with resources such as textbooks, articles, and journals. Medscape, Up-to-Date, and ePocrates as supplemental resources are acceptable. Please also answer all questions in details with in text citation.
Case Study 6.1 – Seizure Disorder
5Please answer BOTH case studies for Gigi Van-Tran & Irving Olson.
CASE STUDY A.
Chief Complaint: Gigi, a 14-year-old female with episodes of “Blanking Out.”
Gigi Van-Tran is brought to your office because of episodic “blanking out” which began one month ago. The patient has episodes in which she abruptly stops all activity for about 10 seconds, followed by a rapid return to full consciousness. The patient’s eyes are open during the episodes, and she remains motionless with occasional “fumbling” hand movements.
After the episode, the patient resumes whatever activity she was previously engaged with no awareness that anything has occurred. She has 30 episodes per day. No convulsions.
Her past medical, physical and developmental histories are unremarkable. Family history is pertinent for her father having similar episodes as a child. Her physical and neurological examination is within normal limits. Laboratory tests including a CBC, chemistries and toxicology screen were normal.
The following questions and images may help guide your discussion:
- What additional studies do you perform, if any?
- What is the diagnosis? What is your differential diagnosis? Please explain.
- How do you initiate medication? If so, Which?
- What considerations must be made since she is a woman of child-bearing potential?
- Would you counsel the family regarding prognosis?
- How would you evaluate the patient in the ER if you saw her after this episode?
- Are there considerations regarding the oral contraceptive pill?
- What work-up is needed after a single seizure?
- What are the causes of seizures, including what conditions lower the seizure threshold?
- Would you treat this patient or not? If you choose to start a medication, which drug would you choose and why?
- What are the predictors of seizure recurrence? Please explain based on its cellular pathology.
CASE STUDY B:
Irving Olson, a 75-year-old male without significant previous history of seizures presents to the E R following one generalized tonic-clonic seizure. Initial assessment after the first seizure revealed poorly reactive pupils, no papilledema or retinal hemorrhages and a supple neck. Irving has an active diagnosis of Emphysema (diagnosed 11/2015). He is allergic to penicillin (anaphylaxis). He currently takes Salmeterol 100/50 1 inhalation twice daily for his emphysema.
His oculocephalic reflex is intact. Respirations are rapid at 22/min and regular, heart rate is 105 with a temperature of 101. As you are leaving the room, the patient had another seizure.
What should the initial management be?
- What initial investigations should be performed in this setting?
- What is the appropriate management with continued seizures if initial therapy does not terminate the seizures?
Laboratory Study Results:
You obtain an MRI of the brain with the following images:
The following questions and images may help guide your discussion:
- Which of the above studies helps to explain the current seizures?
- Would you ask for other studies?
- What are the CSF findings during repeated convulsions?
- Define Status Epilepticus and what causes this condition?
- Describe the systemic manifestations of status epilepticus and the role of EEG in status epilepticus management?
Case Study 6.2 – Substance Use Disorder
Erik is a 19-year-old culinary school student who presented with his mother, complaining of anergia (abnormal lack of energy) and difficulty concentrating. He refused to have his mother present during the intake assessment. Erik does not want to sign the medical release form, stating that it can work against him. He reports that he was fired from a restaurant three months ago after being caught drinking wine left on a table.He claims that he was tricked to drink the alcohol by his coworkers. Not long after the incident, he stopped going to school and sleeps during the day and stays out all night to hang out with friends until the last month. He broke up with his girlfriend a few weeks ago and stopped hanging out with friends. He says they were bad-mouthing him. He also reports that he is afraid to sleep at night because he can hear them talking about him.
Erik started drinking at 12, and his drinking gradually increased over the years. He now drinks secretively at home when his parents are not around. He started smoking marijuana at 15 and used to smoke only with friends. Lately, he uses it almost every day and leaves home only to buy joints. He used up most of his money saved for tuition. He denies using any other illegal drugs or prescribed medications for non-medical use.
Erik does not have any prior psychiatric history and denies family history except that his father drinks alcohol almost every day and one of his cousins was diagnosed with ADHD. He is asking whether he might have the same problem and if he can have the same medication that his cousin takes. He has no acute medical concerns, no chronic conditions and is not on any medications, herbal, or dietary supplements. Erik is in your office today and mildly agitated after you explained the lack of support for him having an ADHD diagnosis.
1) Using the DSM V diagnostic criteria and hallmark symptoms, what is the diagnostic possibility that is most appropriate for this case study? What would substantiate and differentiate the diagnosis? (Please refer to the diagnostic criteria and exclusionary criteria in the DSM to answer this question).
2) Please discuss other related conditions (at least two differential diagnoses) which may need to be ruled out or can be ruled out and why/how as outlined in the DSM. This is an important section as it justifies your clinical impression by walking your faculty through your diagnostic decision making.
3) What psychosocial and environmental problems are important to consider in this case in terms of treatment and prognosis of this identified mental disorder?
