HuBio 564: Principles of Pharmacology II
Case Study 8
A 25-year-old left-handed woman was admitted after a seizure. She was observed by a friend to have an apparent convulsion, with stiffening of her entire body, followed by rhythmic symmetrically contractions, with urinary incontinence. Later, it was discovered that she had also bit the inside of her mouth during this event. The friend was woken up by this seizure, but didn't see how it began.
She was brought to the emergency room. There she was confused, but rapidly returned to normal. Examination and laboratory tests, consisting of a complete blood count and electrolytes were normal, as was a noncontrast CT scan of the head. She was given 18 mg/kg of intravenous phenytoin, told to take 300 mg every night, and given an appointment to see you in the clinic for further evaluation.
When you saw her, she gave a history of occasional subjective episodes in which she has had a few times over the past year. These episodes consist of intense feelings of familiarity--she would feel that whatever was happening at the moment she had experienced before. Sometimes she would feel fear and a rapid heartbeat during them. She denies ever losing awareness during these episodes but her friend disagrees--"last week you told me you were having one of those episodes, and then you stared and didn't answer me." A complete physical and neurological examination was normal.
1. What further evaluation would you do?
Her phenytoin level was 15. The other tests were normal.
2. What would you tell the patient about taking medication? What other advice or instructions would you give to the patient? She also informs you that she is getting married in June.
One week later, she called you to report that she woke up with a rash over her neck and trunk. You told her to come in right away. You find that the rash was red and itchy and was beginning to spread to her arms and legs. She had no fever and her mouth and mucous membranes were not affected.
3. What is the cause of the rash? What do you do?
She is now on levetiracetam. A few weeks later, she calls you because she is very depressed. She normally does not suffer from depression, and wasn't this way after she had suffered her seizure. Although she is not suicidal, her depression is intolerable, and she is not able to work.
4. Why is she depressed?
5. What would you do?
She was changed to lamotrigine, and it is now 9 months later. The patient has faithful followed your recommendations, and despite trials of two other medications at maximal tolerated doses, she is having 2 seizures a month. In your office, she says, "Doctor, I've lost my job, and I can't drive because of these seizures. We want to have a baby, but I'm afraid to with these seizures and all the drugs you have me on."
6. What do you do next?
Use the Submit Case Report button or go to http://depts.washington.edu/phcol/case_sub.html to submit this case.
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