Case Study: Right temporal lobe epilepsy Group Members • Rudolf Cymorr Kirby P. Martinez • Yet dalen • Rachel Joy Alcalde • Siriwimon Luanglue • Mary Antonette Pineda • Khayay Hlaing • Luch Bunrattana • Keo Sereymonica • Sikanal Chum • Pyone Khant khant • Men Puthik • Chheun Chhorvy Advisers: Sudasawan Jiamsakul Janyarak Supat 2 Overview of Epilepsy 3 Overview of Epilepsy 4 Risk Factor of Epilepsy 5 Goal of Epilepsy Care 6 Case of Patient X Patient Information & Hx • Sex: Female (single) • Age: 22 years old • Date of admission: 15 June 2017 • Chief Complaint: Jerking movement of all 4 limbs • Past Diagnosis: Temporal lobe epilepsy • No allergies, family history & Operation Complete Vaccination. (+) Developmental Delay Now she can take care herself. Income: Helps in family store (can do basic calculation) History Workup Admission Operation ICU Female Surgery D/C 7 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs History Past Present History Workup Admission Operation ICU Female Surgery D/C 8 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs Past Present (11 mos) (+) high fever. Prescribed AED for 2-3 Treatment at Songkranakarin Hosp. mos. After AED stops, no further episode Prescribe AED but still with 4-5 ep/mos 21 yrs 6 yrs Present PTA PTA (15 y/o) (+) jerking movement (15 y/o) (+) aura as jerking Now 2-3 ep/ mos both arms and legs with LOC movement at chin & headache Last attack 2 mos for 5 mins. Drowsy after attack ago thus consult with no memory of attack 15-17 episode/ mos History Workup Admission Operation ICU Female Surgery D/C 9 • Sex: Female Case of Patient X • Age: 22 years old • CC: Jerking movement of all 4 limbs Past Present 2 months prior to admission, she had jerking movement both arms and legs, blinking both eyes, corner of the mouth twitch, and drool. She had seizure about 1 minutes. After that she still drowsiness, she can’t answer the question. 3 minutes after, she can answer questions appropriately History Workup Admission Operation ICU Female Surgery D/C 10 Case of Patient X Imaging & Laboratories 11 MRI: (03 April 2016) HLA-B*1502: negative relatively small right hemisphere with encephalomalacic change on right temporal lobe Psychological Test: WAIS-IV and WMS-III VDO EEG: (27 Feb - 3rd Mar 2017) generalized epilepsy and focal epilepsy arising Chest X-ray: Normal from the bilateral fronto- temporal regions. Two clinical seizures, consisting right eyes head versive Urinalysis: Normal then axial tonic seizures then generalized tonic seizure association with left fronto-temporal EEG Principle Diagnosis: seizure patterns were recorded. There is also Right temporal lobe evidence of structural abnormality in the setting of epilepsy/Intractable mild severe diffuse encephalopathy. epilepsy/Mental retardation History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 12 15 June, 2017 Vital Sign Maintenance T= 37 C; P=98/min; Pb (60mg) RR=20/min; 1.5 tab HS BP=114/60 mmHg Levi (500mg) 2 Pre-op Meds tab BID PC Cefazolin 2g LTG(100mg) Single dose 1.5 tab BID PC History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 13 15 June, 2017 16 June, 2017 Vital Sign Maintenance R Temporal T= 37 C; Lobectomy P=98/min; Pb (60mg) RR=20/min; 1.5 tab HS BP=114/60 No complications mmHg Levi intraop (500mg) 2 Pre-op Meds tab BID PC Trans-out the next day Cefazolin 2g LTG(100mg) Cefazolin 1g q Single dose 1.5 tab BID PC 6hr for 4 doses History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 14 15 June, 2017 16 June, 2017 17 June, 2017 Fentanyl 50 mcg/ Vital Sign Maintenance R Temporal IV q 4hr PRN T= 37 C; Lobectomy P=98/min; Pb (60mg) 1 epilepsy ep RR=20/min; 1.5 tab HS (6am) BP=114/60 No complications intraop mmHg Levi Loss cons;, move (500mg) 2 her arms and legs Pre-op Meds tab BID PC Trans-out the next day without direction Cefazolin 2g LTG(100mg) then corner of the Cefazolin 1g q Single dose 1.5 tab BID mouth twitch for PC 6hr for 4 doses 20 minutes History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 15 Post op seizure attack 17 June, 2017 1 epilepsy ep Ictal Post ictal 30 (6am) mins. GCS E 2-3, M5, V2 E 3, M6, V5 Loss cons;, move her arms and legs without direction Pupillary reflex 3 mm RTL BE 3 mm RTL BE then corner of the mouth twitch for 20 minutes Muscle strength 4 on all 4 on all extremities extremities Valium 10mg/IV History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 16 15 June, 2017 16 June, 2017 17 June, 2017 18 June, 2017 Fentanyl 50 mcg/IV No complications Vital Sign Maintenance R Temporal D/C: June 20 T= 37 C; Lobectomy 1 epilepsy ep P=98/min; Pb (60mg) (6am) RR=20/min; Maintenance 1.5 tab HS No complications BP=114/60 Loss cons;, move intraop mmHg Levi her arms and legs Ibuprofen (500mg) 2 without direction (400mg) BID Pre-op Meds tab BID PC Trans-out the for 10 doses next day then corner of the mouth twitch for Cefazolin 2g LTG(100mg) Para (500) Cefazolin 1g q 20 minutes Single dose 1.5 tab BID PRN every 6 PC 6hr for 4 doses Valium 10mg/IV hours History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 17 Post op seizure attack Before discharge 18 June, 2017 – June 17 (ICU) (June 18) No complications Ictal Post ictal D/C: June 20 30 mins. Maintenance GCS E 2-3, E 3, M6, V5 E 4, M5, V6 M5, V2 Ibuprofen Pupillary 3 mm 3 mm RTL 3 mm RTL BE (400mg) BID reflex RTL BE BE for 10 doses Muscle 4 on all 4 on all 5 on all extremities Para (500) strength extremiti extremities PRN every 6 es hours History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Course in the Ward 18 15 June, 2017 16 June, 2017 17 June, 2017 18 June, 2017 Fentanyl 50 mcg/IV No complications Vital Sign Maintenance R Temporal D/C: June 20 T= 37 C; Lobectomy 1 epilepsy ep P=98/min; Pb (60mg) (6am) RR=20/min; Maintenance 1.5 tab HS No complications BP=114/60 Loss cons;, move intraop mmHg Levi her arms and legs Ibuprofen (500mg) 2 without direction (400mg) BID Pre-op Meds tab BID PC Trans-out the for 10 doses next day then corner of the mouth twitch for Cefazolin 2g LTG(100mg) Para (500) Cefazolin 1g q 20 minutes Single dose 1.5 tab BID PRN every 6 PC 6hr for 4 doses Valium 10mg/IV hours History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 19 Cefazolin 2g SD then 1g q 6h for 4 doses Fentanyl 50 mcg/ IV q Mech of action 4hr PRN Diazepam 10mg/IV Common Side Effects Pb (60mg) 1.5 tab HS Levi (500mg) 2 tab BID PC Adverse Reaction LTG(100mg) 1.5 tab BID PC Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 20 Cefazolin 2g SD then 1g q 6h for 4 doses Cephalosporin – binds to 1 or more Fentanyl 50 mcg/ IV q of the penicillin-binding proteins 4hr PRN Diazepam 10mg/IV Diarrhea, stomach cramps, oral candidiasis, vomiting, nausea, skin rash, phlebitis Pb (60mg) 1.5 tab HS Levi (500mg) 2 tab BID PC Pseudomembranous colitis, anorexia, eospinophilia, Steven Johnson’s syndrome, LTG(100mg) 1.5 tab BID PC increased BUN and creatinine, renal failure, genital and anal pruritus, Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 21 Cefazolin 2g SD then 1g q 6h for 4 doses Potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain Fentanyl 50 mcg/ IV q pathways by binding to stereospecific receptors w/in 4hr PRN the CNS. Diazepam 10mg/IV Pb (60mg) 1.5 tab HS Bronchoconstriction, laryngospasm, nausea, vomiting, bradycardia, edema, dizziness, drowsiness, Levi (500mg) 2 tab BID PC hypotension, increased ICP, itching, rash LTG(100mg) 1.5 tab BID Potentially fatal respiratory depression, epistaxis, PC dental carries, gum line erosion, taste perversion Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 22 Cefazolin 2g SD then 1g q 6h for 4 doses Long-acting benzodiazepine with anticonvulsant, Fentanyl 50 mcg/ IV q anxiolytic, sedative – increases neuronal membrane 4hr PRN Diazepam 10mg/IV Shakiness and unsteady walk, trembling, or other problems with muscle control or coordination Pb (60mg) 1.5 tab HS Levi (500mg) 2 tab BID PC Abdominal or stomach pain, black tarry stools, blurred vision, dark urine, decrease urine output, tachycardia, LTG(100mg) 1.5 tab BID PC increased muscle spasms, slurred speech, trouble concentrating, vomiting of blood Ibuprofen (400mg) BID for 10 doses Para (500) PRN every 6 hr Mech of action Common Side Effects Adverse Reaction History Workup Admission Operation ICU Female Surgery D/C Case of Patient X Medication Analysis 23 Cefazolin 2g SD then 1g q 6h for 4 doses Long-acting barbiturate- depresses the sensory Fentanyl 50 mcg/ IV q cortex, reduces motor activity, changes cerebellar 4hr PRN function and produces sedation Diazepam 10mg/IV Pb (60mg) 1.5 tab HS Residual sedation, drowsiness, lethargy, vertigo, nausea, vomiting,headache Levi (500mg) 2 tab BID PC LTG(100mg) 1.5 tab BID Bradyardia, hypotension; anxiety, CNS excitation or PC depression, hyperkinesias, constipation, Ibuprofen (400mg) BID hypoventilation, respiratory