Chief complaint (provided by football coach):
“His arms and legs were rigid as lead pipes. His eyes were rolling, and he was shaking all over. It was horrible! I’ve never seen one in person before, but I think that he had a convulsion”
C.S. is a 17 year old boy who was brought to the emergency room by his high school football coach and two teammates. The patient had been practicing for Friday night’s high school football game when clinical manifestations developed suddenly. It had been a very hot afternoon and all of the players were sweating profusely. When the offensive line positioned itself to run a final play from scrimmage for the afternoon, the patient fell to the ground and appeared to lose consciousness. His body stiffened with arms and legs extended. He suddenly let out a shrill cry and appeared to stop breathing for about 15 seconds. The coach removed his football helmet just before C.S. went into a series of violent, rhythmic, muscle contractions accompanied by hyperventilation. His eyes were rolling and his face became grossly contorted. Suddenly, the jerking movements began to ease up and progressively became less intense until they stopped all together. He then took a deep breath and the incident seems to be over. The entire episode lasted approximately 3-4 minutes. C.S. woke up confused with no recall of the attack. However, he complained of a headache and extremely sore muscles.
The patient complained to his mother that morning before school of a “lightheaded feeling” and she had strongly suggested that he consider skipping practice today. He dismissed the symptoms with, “I’ll be fine” and “It will pass.” Just before he left for practice, his mother asked him how he was feeling. He reported that he “was feeling fine and ready for a good practice.”
Normal pregnancy and delivery of patient
Developmental milestones all WNL
No previous history of seizures
No recent infections
History of one concussion while playing football 2 years ago
Diagnosed with mild hypertension at age 15, taking a low dose of a diuretic
Younger brother diagnosed with epilepsy at age 3
Older sister and father alive and in good health
Mother has osteoarthritis
Denies alcohol or drug use
Reports no unusual stress
Denies tobacco use
Plays offensive tackle
Enjoys “fixing up his car” and hanging out with friends
Reports feeling weak and sleepy
No nausea, vomiting, bowel or bladder incontinence during or after incident
HCTZ 12.5 PO daily
Physical exam and labs:
General: obese white teenage male who is alert but tired, in NAD wearing a football uniform moist from diaphoresis
VS: T: 98.4, HR 80 regular, BP 125/79, R 15 unlabored, Ht 6”3, wt 252 lb
Skin: warm, moist and pale. Face is flushed no lesions
HEENT: atraumatic, pupils round and equal responsive to light, conjunctiva pink but dry, visual acuity 20/20 bilaterally, fundi with sharp disks and no abnormalities, nasal mucosa pink but dry without lesions or discharge, bite wounds on right lateral tongue and inside right cheek, tongue dry and rugged, pharynx dry with no exudate
Neck: supple, no lymphadenopathy, JVD, or bruits, thyroid normal
Chest: Lungs CTA bilaterally, normal diaphragmatic excursion, chest expansion full and symmetric
Heart: apical pulse normal at 4th ICS, MCL. Regular rate and rhythm, S1 and S2 no murmurs, rubs, or gallops
Abdomen: obese, soft, non tender, BS present, no masses or bruits
Musc: brisk capillary refill, no edema, clubbing or cyanosis, Full ROM
Neuro: Oriented but sleepy, cranial nerves intact, muscular tone and strength 5/5 throughout, DTRS 2 + and symmetric, sensory intact to touch, no motor deficits, negative Babinski, cerebellar function and gait normal
Na 127 Ca 9.8 WBC 7.6
K 4.5 Mg 2.3 Diff Neutro 65%
Cl 96 Po4 2.5 AST 12
HCO3 28 Hgb 15 ALT 16
BUN 16 Hct 48% Bili total 0.6
Cr 1.0 MCV 92.5 ALb 4.3
Glucose 100 Plt 191,000 Protein 6.7
Brain MRI scan results: normal
EEG: generalized background slowing, no focal changes or epileptiform activity, photic stimulation did not induce changes in pattern
Clinical course: While in the emergency room, the patient became progressively irritable and anxious and experienced a second seizure with a sudden loss of consciousness and a generalized tonic convulsion that was closely followed by alternating clonic convulsions. The event lasted for approximately 3 minutes. The patient slept for 15 minutes after the seizure and awakened confused. Ht ewa treated with intravenous fosphenytoin to provide long term seizure control, and his electrocardiogram was monitored for cardiac rhythm abnormalities (which are potential side effects when phenytoin is rapidly administered).
A second physical exam revealed a regular heart rate at 115, a regular and unlabored respirations at 20, and a blood pressure of 140/85. His lungs were clear to auscultation. His skin was diaphoretic, warm, and not cyanotic. The patient was sleepy and oriented to name only. A focused neuro exam was essentially normal. Blood was drawn within 20 minutes after termination of clonic phase of the seizure and submitted for prolactin determination. The level was 462.
The patient was admitted to the hospital, monitored closely throughout the night, and continued on fosphenytoin. He did well with no further seizures. He continued to feel weak and tired but had no other adverse effects. He was discharged on the morning of the third day and referred to specialist for further treatment.
Case Question 1: Identify two potential significant contributing factors to this patient’s seizure
Case Question 2: Identify a minimum of eight clinical manifestations in this patient that are consistent with the diagnosis of a grand mal seizure.
Case Question 3: Identify the single most critical lab result in table above that may have contributed to the patient’s seizure.
Case Question 4: Provide an explanation for the abnormal lab finding that you identified above.
Case Question 5: What is the significance of the prolactin test?
Case Question 6: What do you consider the most appropriate initial treatment trial for control of further seizure activity in this patient?