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A 43 year old man with epilepsy
A 43 year old man with epilepsy for 15 years comes to see you, his new PCP, because he has just
relocated to the area. For the first several years, he was well controlled with phenytoin monotherapy. He
began having seizures despite doses high enough to make him “a little wobbly.” Since then, he has been
on carbamazepine, valproate, mysoline, and gabapentin in various combinations, but continued to have
generalized seizures monthly. On his current regimen, oxcarbazepine and lamotrigine, he has
generalized seizures less frequently—every 3-4 months—but has episodes weekly where, according to
observers, he stops talking and hold the right hand up for 1-2 minutes. Several EEGs were normal, but
one showed left temporal lobe spikes. Cranial MRI 12 years ago was said to be normal. He relocated to
move in with his sister, because he hasnʼt been able to work due to his seizures. In addition to
oxcarbazepine, he takes paroxetine for depression. He appears somewhat melancholy, but has normal
language function. The rest of his neuro examination is normal in detail.Click here
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?
Case 48
A 43 year old man with epilepsy for 15 years comes to see you, his new PCP, because he has just
relocated to the area. For the first several years, he was well controlled with phenytoin monotherapy. He
began having seizures despite doses high enough to make him “a little wobbly.” Since then, he has been
on carbamazepine, valproate, mysoline, and gabapentin in various combinations, but continued to have
generalized seizures monthly. On his current regimen, oxcarbazepine and lamotrigine, he has
generalized seizures less frequently—every 3-4 months—but has episodes weekly where, according to
observers, he stops talking and hold the right hand up for 1-2 minutes. Several EEGs were normal, but
one showed left temporal lobe spikes. Cranial MRI 12 years ago was said to be normal. He relocated to
move in with his sister, because he hasnʼt been able to work due to his seizures. In addition to
oxcarbazepine, he takes paroxetine for depression. He appears somewhat melancholy, but has normal
language function. The rest of his neuro examination is normal in detail.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis? click here