Keyshawn Johnson is an 18 y/o male no PMH BIBEMS with a compliant of first onset seizure.

 History Elements

• Seizure was witnessed by mother
• No previous history of seizure
• Pt was getting ready for school and suddenly fell on the floor mother then saw the patient shaking and foaming at the mouth
• Mother states episode lasted for around 2 minutes
• Pt does not recall the events himself
• EMS states patient was Alert and oriented x 2 on their arrival
• Mother has h/o epilepsy and generalized tonic-clonic seizures.
• No urinary or fecal incontinence during episode
• No head trauma
• No tongue biting during episode
• Denies smoking and illicit drug use
• Not currently on medications or herbal supplements
• No fever, chills, SOB, nausea, vomiting, or diarrhea
• No dizziness, headache, numbness, tingling, or weakness
• No h/o HTN or DM

Physical Exam

• Vital Signs- BP 113/79, HR 84, R 16, T 97.6
• General: Thin male, neatly groomed, looks younger than her stated age of 18 years, Alert and Oriented x 3, not in any acute distress.
• Motor/Cerebellar: Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout. Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.
• Mental Status: A&O x 3, cooperative, thoughts & speech coherent.
• Cranial Nerves: II-XII intact
• Sensory: Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally
• Reflexes: 2+ throughout, negative Babinski, no clonus appreciated
• Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
• Head: normocephalic, atraumatic, non-tender to palpation throughout
• Tongue – Pink; well papillated; no masses, lesions, or deviation.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU Visual fields full OU. PERRLA, EOMs intact with no nystagmus
• Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
• Heart: PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Differential Diagnosis

• Brain hemorrhage: Even though patient denies any recent head trauma this could possibly be the cause of his seizure. There is also a possibility that he suffered head trauma during the seizure so this needs to be ruled out.
• Stroke: Given pt young age and pt has no apparent risk factors such as HTN or DM, no obvious neural deficits, this still needs to be ruled out given this is a first time and seemingly unprovoked seizure. There is also a possibility that pt has smoking history and simply denied it during interview because of comfortability.  
• Cardiogenic syncope: Even though the patient’s mother is stating that she witnessed the seizure it is possible the patient had a syncopal episode.
• Brain tumor: unlikely due to pt age but needs to be ruled out given first onset of unprovoked seizure.
• Hypo/hyperglycemia: Even though patient has no history of DM it is possible that his sugar levels either caused him to syncopize or caused his seizure.
• Electrolyte abnormalities: Even though pt denies any risk factors for evident electrolyte abnormalities such as vomiting or diarrhea. This still needs to be on the differential seeing that it is a common cause for unprovoked seizures.
• Substance Abuse: Even though the patient denies h/o substance use this still needs to be taken into consideration seeing that pt had what seems to be an unprovoked seizure and is 18 years of age.
• Grand Mal seizures: Pt. is complaining of first onset seizure, loss of consciousness, mother characterizes his episodes as a “shaking”, and has an unremarkable physical exam. Mother also reports a h/o of seizures herself.

Tests

• POC glucose – 80 mg/dL
• CBC – with in normal limits
  • WBC: 6.29 
  • RBC: 5
  • HGB: 15
  • HCT: 50
  • MCV: 91.7
  • MCH: 31.5
  • MCHC: 34.3
  • RDW: 14.4
  • PLT: 153
• BMP – within normal limits
  • Na: 138
  • K: 3.8
  • Cl: 102
  • CO2: 24
  • BUN: 13
  • Cr: 0.82
  • GLU: 83
  • Anion: 12
  • Ca: 9.1
  • BUN/Cr: 16
• Hepatic function Panel- within normal limits
  • Protein Total  7.4     
  • Albumin Level        4.9     
  • Globulin        2.5     
  • Bilirubin Total        0.4     
  • Bilirubin Direct       0.1    
  • Bilirubin Indirect    0.3     
  • Aspartate Aminotransferase      23      
  • Alanine Aminotransferase         22      
  • Alkaline Phosphatase              100     
• UA – no significant abnormalities
  • Color:   Pale yellow
  • Clarity:  Clear
  • pH: 6.5
  • Specific gravity: 1.010
  • Glu: negative
  • Blood: negative
  • Ketones: negative
  • Protein: negative
  • Urobilinogen: negative
  • Bilirubin: negative
  • Leukocyte esterase: negative
  • Nitrite: negative
• Tox screen – negative
• BAL – negative
• Serum lactate – with in normal limits
  • 1.03 mmol/L
• ECG
  • normal sinus rhythm, HR 70, PR interval <0.2 seconds, QTC interval <440 ms, no acute st segment changes
• Head CT
  • No mass, hemorrhage, or hydrocephalus. Basal ganglia and posterior fossa structures are normal. No established major vessel vascular territory infarct. No intra or extra axial collection. The basal cisterns and foramen magnum are patent. The air cells of the petrous temporal bone are non-opacified. No fracture demonstrated.

• CTA head and neck
  • Intracranial circulation is unremarkable with no vascular malformation, aneurysm, or stenosis. No branch occlusion.
• EEG
  • Normal awake EEG record not showing any seizure activity.

Treatment

• In house neurology consult
• Keppra 500 mg PO BID

Patient counseling

• Follow up outpatient neurology.
• Advise patient on common triggers for seizure such as medication, sleep deprivation, and alcohol.
• Advise patient to avoid unsupervised activities that might pose danger with sudden loss of consciousness, including bathing, swimming alone, working at heights, and operating heavy machinery.
• Counsel the patient on driving restrictions.
• Ask the patient if they have any questions and to explain the situation in their own words to make sure he understands the important points.

Sources:

https://www.uptodate.com/contents/evaluation-and-management-of-the-first-seizure-in-adults?search=first%20onset%20seizure&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1860320207

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1363913/

https://www.uptodate.com/contents/initial-treatment-of-epilepsy-in-adults

https://www.aafp.org/pubs/afp/issues/2007/0501/p1342.html