- Patient Presentation Chief Complaint I Had A Seizure A Few Weeks Ago And Banged Up My Head Hpi Carter Mcneely Is A 1 (76.99 KiB) Viewed 36 times
PATIENT PRESENTATION Chief Complaint "I had a seizure a few weeks ago and banged up my head." | HPI Carter McNeely is a 68-year-old man whose seizures are well controlled with carbamazepine monotherapy. The seizure from 2.5 weeks ago was the first seizure in 20 months. During the seizure, he fell to the floor and sustained a laceration to his occipital region that required staples for closure. The description of his seizures is vague because there have been only six seizures documented since he developed epilepsy 3 years ago. Because Mr McNeely lives alone in an assisted living facility, only half of the documented seizures have been witnessed by another individual who could provide a description. Two seizures were witnessed by other residents who described him as "falling to the ground and
starting to shake." One seizure occurred in the day room when a facility nurse was in the room, and he documented that Mr McNeely fell to the ground, developed rhythmic extensions to both his legs, became incontinent of urine, and was sleepy and disoriented for 2 hours after the episode. He has only been treated with carbamazepine. This was started by his family practice physician after his second seizure. An EEG was obtained at that time and was unremarkable. Because the seizures are so infrequent, the dose of carbamazepine has never been adjusted. ■PMH Tonic-clonic seizures diagnosed 3 years ago HTN adequately controlled with lisinopril monotherapy Dyslipidemia controlled with atorvastatin and low-cholesterol diet BPH, currently symptom-free on dutasteride ■FH Mother died at age 74 of "natural causes"; had HTN for many years. Father died at age 70 of "natural causes"; did not have any known medical illnesses. All of his children and grandchildren are alive and well. One son and one daughter have HTN. SH Retired factory worker; resides in an assisted living facility. He is widowed and has six children and nine grandchildren, whom he sees frequently. He denies past or present tobacco and illicit drug use. He reports a history of regular alcohol use but now only drinks one beer that his grandson brings to him every Saturday evening.
Meds Aspirin 81 mg PO once daily Atorvastatin 40 mg PO once daily Carbamazepine XR 200 mg PO twice daily Dutasteride 0.5 mg PO once daily Lisinopril 20 mg PO once daily Multivitamin with minerals one tablet PO once daily All NKDA
Adverse drug effect history-none Physical Examination Gen Exam reveals an elderly Caucasian man who appears his stated age in NAD VS BP 126/78 mm Hg, HR 72, RR 16, temperature not measured; Ht 5'10", Wt 72.5 kg HEENT Normocephalic; scalp: healing 3-cm lesion in the occipital region with corresponding mild tenderness and bruising; PERRL Neck/LN No thyromegaly, lymphadenopathy, or carotid bruits Chest/Lungs Lungs CTA CV RRR, no m/r/g Abd Soft, nontender; no HSM; (+) BS
Na 127 mEq/L K 4.7 mEq/L Cl 90 mEq/L CO, 25 mEq/L BUN 10 mg/dL SCr 0.6 mg/dL Glu 100 mg/dL Hgb 13.5 g/dL Hct 41% RBC 3.9 x 100/mm³ WBC 5.1 x 10%/mm³ Diff WNL MCV 97 μm³ Carbamazepine 6 mcg/mL Fasting Lipid Profile T. Chol 155 mg/dL TG 123 mg/dL HDL-C 39 mg/dL LDL-C 91 mg/dL EEG Sleep-deprived EEG unremarkable. Photic stimulation failed to produce any other changes ■Assessment Sixty-eight-year-old man with fairly well-controlled seizures on carbamazepine monotherapy
QUESTIONS Problem Identification 1.a. What are this patient's drug therapy problems? 1.b. What additional information is needed to fully assess the patient's problems related to epilepsy or his drug therapy? 1.c. What are the age-specific management issues for this patient? Desired Outcome 2. What are the goals of pharmacotherapy in this case? Therapeutic Alternatives 3.a. What nonpharmacologic interventions may be helpful for this patient? 3.b. What pharmacotherapeutic options are available to treat his epilepsy? Optimal Plan 4. What is the best pharmacotherapeutic plan for this patient?
Outcome Evaluation 5. Which clinical and laboratory parameters are needed to evaluate the therapy to ensure the best possible outcome? Patient Education 6. What information should the patient receive to ensure successful therapy and to minimize adverse effects?