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Case 23
A woman with “grand mal” seizure
A 28 year-old woman comes to the office in follow up from an ED visit for a “grand mal” seizure. In
reviewing her ED records, you make note of a paramedic run sheet describing shaking of all extremities
accompanied by foaming at the mouth and deviation of eyes to the left. In the ED she was afebrile with a
“nonfocal” neuro exam and normal head CT, electrolytes, and tox screen. She received lorazepam 4mg
in the field. She was reported to the DMV and not begun on any medications. Just before the seizure,
she smelled “burning rubber” and experienced a rising feeling in her stomach. She had another seizure
with loss of consciousness 18 months ago, but did not seek medical attention because she did not have
medical insurance.
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, consultations) would you
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? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about her condition and about any proposed
therapy?
Case 23
A 28 year-old woman comes to the office in followup from an ED visit for a “grand mal” seizure. In
reviewing her ED records, you make note of a paramedic run sheet describing shaking of all extremities
accompanied by foaming at the mouth and deviation of eyes to the left. In the ED she was afebrile with a
“nonfocal” neuro exam and normal head CT, electrolytes, and tox screen. She received lorazepam 4mg
in the field. She was reported to the DMV and not begun on any medications. Just before the seizure,
she smelled “burning rubber” and experienced a rising feeling in her stomach. She had another seizure
with loss of consciousness 18 months ago, but did not seek medical attention because she did not have
medical insurance.
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, consultations) would you
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? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about her condition and about any proposed
therapy?A woman with “grand mal” seizure.