2. Definition
• A seizure is a paroxysmal event due to abnormal, excessive,
hypersynchronous discharges from an aggregate of CNS neurons.
• Epilepsy describes a condition in which a person has recurrent seizures
due to a chronic, underlying process.
10. Tonic Seizures
o
o
When a tonic seizure occurs, the muscles in the body contract and the
entire body stiffens
And it often causes the person to fall down
Atonic seizures
o
o
o
Characterised by loss of postural tone lasting 1-2 secs
Consciousness is briefly impaired
No post ictal confusion
Myoclonic seizures
o Characterised by sudden and brief contraction of one part of the body or
entire body
Unclassified Seizures
o
Seizures that occur in neonates and infants
13. Patient details:
IP no: 279411
Age: 15 years
Weight: 53 kg
Sex: Male
Unit: Neurology I
DOA: 17/1/14
Reason for admission:
Recurrence of seizures since 2 days (5 episodes in 2 days lasting 10-20 secs).
14. PMx:
K/C/O: seizure disorder since 8 years (since 2010) and on regular
medications (T. Phenytoin 50 mg- 0 - 50 mg, T. Clobazam 5 mg 1-0-1,
recently started on T. Valproic acid 250 mg 0-0-1).
GTCS type of seizures a/w LOC for 2-3 mins
Post ictal headache (+)
No post ictal confusion
Post ictal myalgia (+)
h/o cough/ headache (+)
No h/o fever in the last week
No h/o vomiting
17. Day 1:
BP: 130/80 mmHg
C/O 6 episodes of GTCS in the morning
O/E: skin lesions (+)
CNS: conscious oriented, clinically no FND
Motor System: Power 5/5, Reflexes (N)
CVS: S1S2 (+)
R/S: B/L NVBS (+), no added sounds.
ADV: Hb, TC, DC, ESR, LFT, Calcium
Pulse: 86 bpm
18. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
simethicone gel
400 mg + 20
mg in 5 ml
PO
BD
+
+
+
+
+
+
Multivitamin
5 ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
Domperidone
40 mg + 10
mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-0-2
+
+
19. Laboratory Data:
Hematology:
Biochemistry:
Hb
14.2 gm/dl (13.5 2 gm/dl)
Bilirubin
WBC
6,900 cells/cu.mm (400011,000 cells/cu.mm)
PLT
2.75 lakhs/cu.mm (1.5-5
lakhs/cu.mm
T 0.60 mg/dl (0.1-1.0 mg/dl)
D 0.20 mg/dl (0.0-0.2 mg/dl)
Total proteins 6.5 gm/dl (6-8 gm/dl)
5 mm/hr (0-10 mm/hr)
Electrolytes:
Ca
9.6 mg/dl (8.8-10.8 mg/dl)
3.6 gm/dl (3.4-5.0 gm/dl)
A/G ratio
1.2 (1.2-2.5)
AST
35 U/L (0-40 U/L)
ALT
ESR
Albumin
34 U/L (0-40 U/L)
ALP
277 U/L (37-306 U/L)
20. Day 2:
BP: 130/80 mmHg
Case reviewed, no fresh complaints
H/o movement of hands at 4:00 am today
O/E no FND, vital stable
Rx: as per chart
Referred to dermatologist for features suggestive of adenoma sebaceum
on face with ash leaf macule on chest.
Derma opinion: H/O burning sensation, lesion on nose and malar area,
photosensitivity, hypopigmented patches since 7 yrs of age
Imp: Xeroderma pigmentosum
Start Suntop 30 cream (octinoxate and micronized zinc oxide lotion) and
Desowen cream (desonide lotion)
21. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
simethicone gel
400 mg + 20
mg in 5 ml
PO
BD
+
+
+
+
+
+
Multivitamin
5 ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
Domperidone
40 mg + 10 mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-02
+
+
22. Day 3:
BP: 110/80 mmHg
Case reviewed, no fresh complaints
O/E no FND, vital stable
Rx: as per chart, Optho opinion
23. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
Simethicone gel
400 mg+ 20
mg in 5 ml
PO
BD
+
+
+
+
+
+
Multivitamin
5 ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
domperidone
40 mg+ 10
mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-02
+
+
24. Day 4:
BP: 110/80 mmHg
C/O 7-8 episodes of myoclonic jerks at night
CNS: no FND
CVS: NAD
Rx: as per chart
Optho opinion: c/o burning sensation and redness of eyes
Imp: NAD
25. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
simethicone gel
400 mg+ 20
mg in 5 ml
PO
BD
+
+
+
+
+
+
Multivitamin
5ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
Domperidone
40 mg + 10
mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-0-2
+
+
26. Day 5:
BP: 126/74 mmHg
Case reviewed, no fresh complaints
CNS, CVS: NAD
Rx: as per chart
27. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
simethicone gel
400 mg + 20
mg in 5ml
PO
BD
+
+
+
+
+
+
Multivitamin
5 ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
Domperidone
40 mg + 10
mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-0-2
+
+
29. Treatment Chart:
Drugs
Dose
Route
Frequency
D1
D2
D3
D4
D5
D6
Valproic acid
250 mg
PO
0-0-1
+
Phenytoin Sodium
100 mg
PO
1-0-1
+
+
+
+
+
+
Clobazam
10 mg
PO
1-0-1
+
+
+
+
+
+
Magaldrate +
simethicone gel
400 mg+ 20
mg in 5 ml
PO
BD
+
+
+
+
+
+
Multivitamin
5 ml
PO
BD
+
+
+
+
+
+
Protein powder
1 tsp
PO
BD
+
+
+
+
+
Pantoprazole +
Domperidone
40 mg + 10
mg
PO
1-0-0
+
+
+
+
+
Fosphenytoin
50 mg
IV
1-1-1
+
+
+
Lamotrigine
25 mg
PO
1-0-1
+
+
1-0-2
+
+
30. Day 7:
BP: 120/80 mmHg
Case reviewed, no fresh complaints
CNS, CVS: NAD
Rx: as per chart
Adv: discharge, review after 1 week in OPD
31. Dishcarge medications:
Drugs
Dose
Route
Frequency
Phenytoin Sodium
100 mg
PO
1-0-1
Clobazam
10 mg
PO
1-0-1
Magaldrate + simethicone gel
400 mg + 20 mg in
5 ml
PO
BD
Multivitamin
5 ml
PO
BD
Protein powder
1 tsp
PO
BD
Pantoprazole + Domperidone
40 mg + 10 mg
PO
1-0-0
Lamotrigine
25 mg
PO
1-0-2
32. Pharmaceutical Care Plan:
Subjective Evidence
Objective Evidence
For seizures
• Seizures since 2 days
• PmHx: K/c/o seizure disorder since
8 years
For seizures
• Nil
For xeroderma pigmentosum
• Photosensitivity
• Burning sensation and lesion on
nose and malar area
• Hypopigmentation
• Irritation and redness of eyes
For xeroderma pigmentosum
• Nil
33. Goals of therapy:
For seizures
• To accurately diagnose the patient's seizure type and epilepsy syndrome
and determine the etiology.
• To identify and eliminate patient-specific seizure precipitants.
• To select optimal anticonvulsant therapy based on seizure type, epilepsy
syndrome, patient age, sex, and concomitant medical conditions.
• To minimize the use of poly-drug therapy and sedating antiepileptic drugs
whenever possible.
• To monitor for clinical and laboratory evidence of adverse effects of drug
therapy.
• To identify and address patient concerns regarding the effect of epilepsy
and its management on daily activities, employment, and social
interactions.
34. For XP
• To protect patient from sunlight and to reduce damaging effect of
UV rays on skin
36. General treatment options
For seizures
Seizure type
First line agents
Second line agents
Partial seizures
Carbamazepine, phenytoin,
lamotrigine, oxcarbazepine,
valproic acid
Levetiracetam, topiramate,
gabapentin, phenobarbital,
primidone, felbamate
Tonic clonic seizures
Valproic acid, lamotrigine,
topiramate
Zonisamide, penytoin,
carbamazepine, oxcarbazepine,
phenobarbital, primidone,
felbamate
Absence seizures
Valproic acid, ethosuxcimide
Lamotrigine, clonazepam
Atypical seizures
Atonic siezures
Myoclonic seizures
Valproic acid, lamotrigine,
topiramate
Clonazepam, felbamate
For XP: sunscreen, vit D supplements, emollients, retinoid preparations,
T4N5 lotion
37. Specific treatment options
For seizures:
GTCS: Valproic acid, lamotrigine, topiramate
Multivitamins: vit B complex, vit D & calcium supplementation
For XP: avoid exposure to sunlight, sunscreen, emollients, vit D
preparations
38. Monitoring parameters:
• EEG
• Electrolytes: Ca, Mg
• Serum glucose
• Neurological status
DISEASE SPECIFIC
• LFTs
• CBC
• Patients adherence to the medications
DRUG SPECIFIC
39. Problems identified:
• Drug interactions: valproic acid and phenytoin ( level of phenytoin)
phenytoin and lamotrigine ( level of lamotrigine)
pantoprazole and clobazam (
effect of clobazam)
• Concomitant use of magaldrate and pantoprazole
• Phenytoin and clobazam not the apppropriate treatment options for
GTCS, moreover phenytoin should not be used in young patients who
require long term therapy with phenytoin
• Use of protein powder
• Concomitant use of phenytoin and fosphenytoin together for 3 days
42. Lifestyle modifications
• Care takers were informed to give stress free environment
• They were advised to monitor him during sleep hours to identify
seizure activity
• They were asked to visit their doctor regularly
• They were informed the benefits of relaxation techniques like deep
breathing and meditation
• They were told to provide him with healthy diet, including plenty of
whole grains, fresh vegetables, and fruits
• They were explained the benefit of high fat, no sugar, low protein
diet
• They were informed to make him wear protective clothes and avoid
sun exposure as far as possible
