1. NYU Medical Grand Rounds Clinical Vignette Megha Shah PGY-2 November 10, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 45 year old man who presented with a three month history of repeated loss of consciousness, accompanied by bilateral upper extremity jerking. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient’s medical history began when he was a child in China, when he reports the onset of a seizure disorder. As a child, he had been on antiepileptic medications, with complete resolution of his seizures just prior to starting high school. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. He was in his usual state of health until 20 years prior to admission when his seizures recurred. He was restarted on his antiepileptic medications at that time. In 2008, the patient moved to the United States, at which time his seizures increased in frequency to approximately twice a week. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. He was seen by an outside physician and his medications were adjusted. He was doing well clinically until three months prior to admission, when his seizures again increased in frequency to twice daily. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Three days prior to admission, the patient had a seizure that lasted approximately three minutes, during which he lost consciousness, had bilateral upper extremity jerking, and a confused state after the seizure. He was then admitted to New York University Langone Medical Center for further evaluation of his seizures. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Additional History Past Medical History: None Past Surgical History: None Social History: Denies any alcohol, tobacco, or illicit drug use Currently unemployed Married with one adult son Family History: No known history of epilepsy Allergies: No known drug allergies Medications: Carbamazepine 400mg twice a day Valproic acid 500mg twice a day Lacosamide 50mg twice a day Multivitamin 1 tablet once a day U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Physical Examination General: Alert and oriented to person, place, and time, in no acute distress. Appeared stated age and answered questions appropriately Vital signs: T: 99.0 BP: 138/94 HR: 99 RR: 20 O2 sat: 99% on room air Neurological exam: cranial nerves II-XII grossly intact, 5/5 strength in all extremities, sensory intact. 2/2 reflexes ankles, knees, biceps, triceps, and toe flexors. Negative Romberg Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings Basic metabolic panel: within normal limits CBC: within normal limits Hepatic panel: within normal limits Carbamazepine level: 7.4 (normal 8-12) Valproic acid level: 47.7 (normal 50-100) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Working Diagnosis Refractory epilepsy U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Day 1: –Antiepileptic medications were held in a progressive manner to provoke seizures, in order to capture them on video electroencephalogram recording. –Lacosamide was held first Hospital Day 2: –Valproaic acid was decreased to 250mg once daily –The patient had two seizures, both with right eye deviation with head turning, and left arm extension. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 3-5: - Carbamazepine and valproic acid were held - The patient had an additional 4 seizures, similar to those he had previously Day of discharge: - All medications were restarted, and the patient was without complaints. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Other Studies Video Electroencephalogram: Cortical hyperexcitability in the right frontotemporal regions consistent with an epileptic focus in the frontotemporal lobe. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. At this time, the patient is currently undergoing preoperative evaluation for possible temporal lobe resection. Interim History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Refractory temporal lobe epilepsy Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS