Read the diagnosis and treatment of epilepsy.

The patient female, 13 years old, Dongguan, Guangdong, due to recurrent seizures of limb convulsions, accompanied by unclear consciousness for a year, aggravated by 1 day on January 4 hospitalization.
patient suddenly had quad convulsions after being tired at about 4pm on January 3 and fell to the ground and lost consciousness.
convulsions initially for the eyes on the head and neck back, the torso is angled bow back, upper limbs clenched fist, lower limbs straight as strong straight, and later the whole body is twitching with the sound of throat and spitting white foam, about 2 minutes of convulsions terminated, about 10 minutes sober.
self-conscious whole body soreness, there is forgetting.
was not in the hospital at the time.
a month later, there was a similar seizure and he went to a local hospital.
to take phenytoin sodium 0.05tid, seizures failed to control and added phenytobarbidium (Luminal) 0.15bid, still have 1 to 2 seizures per month.
three days before he was admitted to hospital, went out to play and stop taking drugs, in the early hours of this morning there were frequent quadriplegic convulsions accompanied by loss of consciousness, interstity consciousness is still not awake with fever and sweat.
first child, full-moon birth, breast milk with artificial feeding, growth and development.
history of non-nuclear jaundice, encephalitis, thermal convulsions, brain trauma, surgery and drug allergy.
cousin had seizures of limb convulsions when he was 5 years old, accompanied by a history of loss of consciousness.
in our hospital neurology diagnosed as "epilepsy (strong straight - convulsive seizures), " after taking anti-epileptic drugs did not see seizures, three years after the suspension of the drug, so far has not seen seizures.
: T39 degrees C, P100 times/min, R32 times/min, BP15/8kPa.
normal development, moderate nutrition.
the whole body skin dry, poor elasticity, mucous membranes no bleeding points and spots, scleres no yellowing.
the body's superficial lymph nodes are not covered.
neck is soft, the trachea is centered, and the thyroid gland is small.
chest symmetry, no deformities, shortness of breath, double lungs can smell sputum chirping.
normal heart boundary, heart rate 100 times / minute, heart rhythm neat, each valve area unheard of and pathological noise.
is flat and soft, liver, spleen and swelling.
spine, limbs without deformities, joints without deformities, redness, swelling, heat.
: consciousness disorders are shallow coma, pressure has painful expressions and inaccurate positioning of the avoidance response.
two-sided pupil diameter of 4.5mm, iso-large and equal circle.
reflects light normally.
under the eye: the nipple color red, the edges clear, retinal veins full of curls.
two-sided nasal lip ditch symmetry, residual cranial nerves were not detected.
there is no abnormality in the muscles of the limbs.
pain stimulation can be seen in autonomous movement, the limbs deep reflection symmetrical normal, abdominal wall reflection is weak, pathological signs are not cited, meninges stimulation signs (-).
on the seizure examination: the patient's eyelids, eyes on the eye, limbs are strong straight a convulsive convulsions, the torso is overstretched, lips bruising, later spitting white foam, sweating, about two minutes of seizures terminated.
inspection found that the double diffuse was about 5mm and the reflection of light disappeared.
laboratory examination: hemoglobin 156g/L, red blood cells 4.50 x 1012/L, white blood cells 12.5 x 109/L.
classification: neutral 0.8, lymph 0.2, plate plate plate 160 x 109/L.
urine routine: urine specific gravity 1.067, protein (-), urine sugar (-), bilirubin (-), ketone body (-), tube type (-).
blood biotransformation: blood sodium 156mmol/L, blood potassium 5.0 mmol/L, blood sugar 6.0mmol/L, blood chlorine 118mmol/L, total calcium 2.5mmol/L, urea nitrogen 7.8mmol/L. Auxiliary examination: emergency electrostatic graph "sinus tatration (116 times/min)", head CT scan not abnormal density.
outpatient brain electricity (seizure interval): the regular record is not normal, excessive breathing can be seen when a lot of bursts of long-range 3-6Hz 250 to 280V slow activity, between ratchet and ratchet-slow compound wave.
discuss intern A: characteristics of this case: (1) female, 13 years old; (2) recurrent quadricups convulsions with loss of consciousness, aggravation of 1 day; (3) family has a similar history of seizures patients; (4) physical examination: T39 degrees C, shortness of breath, shallow coma, cranial nerve, Limb movement, sensation, deep reflection did not see obvious abnormalities, pathological signs did not lead out; (5) seizure examination: the patient showed a typical quadriplegic convulsions accompanied by loss of consciousness; (6) intermittent e-brain diagram: bursts of high wave slow activity, between ratchets and ratchet-slow compound waves.
can be diagnosed as epilepsy based on typical medical history and seizure period tests, as well as the results of electro-encephalograms.
: The diagnosis of epilepsy should be based mainly on a detailed and reliable medical history, such as the examiner can witness the whole process of the seizure, combined with electro-encephalogram results can be diagnosed.
be aware that electro-encephalogram examination is an important auxiliary measure for epilepsy diagnosis, but not an absolute factor.
because 20% of EETs in normal populations can be abnormal, and 20% of epilepsy patients have no abnormal EET results.
type of seizure that is included in the diagnosis of another epilepsy? Is it primary or secondary? What is the secondary cause? The former is conducive to our rational and correct choice of anti-epileptic drugs, the latter provides a basis for the treatment of the cause.
Intern B: Patients with seizures of limbs strong - convulsive convulsions accompanied by loss of consciousness, seizures accompanied by autologous neurological disorders, after the seizure of retrograde forgetting, considered for seizures.
: According to the classification of international seizures, this case should belong to the comprehensive seizures in the strong-tyclonic seizures.
need to be identified as secondary full-scale seizures.
This case of adolescent disease (12 years old), has a positive family history, no obvious precursor and other precursor symptoms before each attack, presents a typical systemic strong-fluclonic seizure, interstitial period no nervous system positioning signs, electroencephalogram double-sided symmetry, synchronous high-wave slow activity and ratchet and ratchet-slow compound wave, skull CT did not see abnormalities.
can be diagnosed as primary epilepsy (full-strength-tymponic seizures).
Intern C: Clinically, some diseases are also mainly the result of limb twitching, how do we distinguish them? Teacher: It is true that some diseases, such as rickets, hypocalcemia and so on, also take limb convulsions as the main manifestation.
but we can distinguish between detailed medical history inquiries, careful examinations combined with laboratories, and other complementary examinations.
Such as rickets patients can have recurrent seizures of limb convulsions, but their seizures are in the field and emotional stimulation, seizures of limb muscles more irregular contraction, the duration of the attack is longer, pupil, corneal reflexes and diaphragm reflexes do not change, unconscious loss, bumps and size incontinence, often accompanied by crying and shouting.
Again, such as low calciumemia, although there are limb convulsions, but its convulsion form is typical "midwife" hand-like, unconscious loss, normal physiological reflection, pathological signs (-), many cause low calcium history, such as fat dysentery or thyroid surgery history, blood calcium, phosphorus assay helps to diagnose.
Intern D: The day before this case was admitted to the hospital, there was frequent limb strength-tymponic convulsions accompanied by loss of consciousness, and each between seizures consciousness is still not awake, and accompanied by fever, sweating, need to consider for the seizure of the continuing state.
: Agree with classmates' analysis.
common causes of persistent epilepsy are drug suspension, drug reduction or sudden drug change, as well as fever, infection, fatigue, etc.
example is related to its suspension of drugs.
due to frequent strong-convulsive nature leading to sustained high heat, high permeable dehydration, white blood cells increased, need to actively rescue.
E: In this case, during outpatient treatment, the use of the anti-epileptic drug phenytoin sodium and phenytosodium phenytobito, why is it still not well controlled seizures? Teacher: Once the epilepsy diagnosis is established, and there is no sign of treatment, the control of seizures is the only and necessary treatment measures.
because drug control seizures is a long-term treatment process, and each anti-epileptic drug has different degrees of side effects, so reasonable medication is particularly important.
is to take medication as early as possible (with the exception of those with seizures of more than one year).
to inform patients and their families of the importance and necessity of long-term drug use, side effects of the drug and precautions in the course of treatment, in order to obtain full cooperation, adhere to the opposition to casual drug replacement.
drug selection: depending on the type of attack, side effects of the drug, the patient's financial situation and source of the drug, the choice of effective, less toxic, easy to buy, cheap drugs.
this case belongs to the primary comprehensive strong-frontal seizure should be preferred sodium valproate, followed by the choice of phenytoin sodium or benzodiaxal.
but the patient took sodium phenytoin, the drug side effect is obvious, the safety range is narrow, resulting in the patient's seizures can not be controlled.
the way of administration depends on the metabolic characteristics of each drug, the principle of drug action and the law of side effects, such as sodium valproate, the dose and plasma concentration are linearly related, so should be used according to the regular dose, due to the large range of safety, can gradually increase the dose with the disease.
And the dose of sodium benzoine and plasma concentration is parabolic linear correlation, small dose rise flat, increase the dose of blood concentration rose sharply, so in the use of drugs from a small dose, poor efficacy, increase the dose should beware of poisoning.
E: Teacher, why not use a two-drug combined treatment when one drug is not effective? Teacher: At present, the International Anti-Epilepsy Alliance still advocates single-drug treatment.
Because the single drug is easy to observe clinical efficacy and the way of drug treatment, can reduce the interaction between multiple drugs caused by chronic poisoning and economic burden, more importantly, 80% to 85% epilepsy can be satisfied with the efficacy.
multidrive therapy is only suitable for persistent epilepsy monodrative treatment failure, or has a variety of seizure types of epilepsy.
the reasons for the poor treatment of single drug in this case, in addition to the above analysis of the drug selection is not right, whether the drug has reached effective blood concentration is also worth noting.
because of the metabolic characteristics of the drug and individual differences, the way of administration by mg/kg can not be sure of clinical needs.
blood concentration should be monitored to adjust the effect relationship in order to achieve the best effective blood concentration.
intern F: This case with phenytoin sodium efficacy is not good, should be replaced with sodium valproate, in the process of drug change we should pay attention to what? Teacher: That's a good question.
usually use an anti-epileptic drug, its efficacy should be observed for not less than 1 to 2 months.
If the efficacy is not good or the toxic reaction is obvious and to replace the new drug, we must increase the new drug at the same time, the original drug will gradually reduce, that is, wait for the effective blood concentration of the new drug to stabilize before withdrawing the original drug, avoid sudden suspension of the drug, otherwise it will lead to frequent seizures, or even induce epilepsy continued state.
Intern C: Once this patient controls the seizure, how long does it take オ can stop taking the drug? Teacher: Medication time depends on the extent of brain injury, seizure control before epilepsy duration, seizure type and EET abnormal development, usually primary large seizures and simple partial seizures, in full control of 2 to 5 years, typical amortization attacks in full control for more than 6 months can be considered to terminate treatment.
should be reduced slowly before stopping the drug.
the longer the course of the disease, the greater the dose, the more medication, the slower the reduction.
the process of stopping the drug may take into account EET changes.
the whole process is not less than 3 months.
if the recurrence needs to restore the original drug quantity, complex partial seizures can rarely be fully controlled, more long-term treatment.
Intern F: The patient's hospitalization department due to self-suspension caused by seizures continued state, combined with high fever, high permeable dehydration, white blood cell elevation.
need to give oxygen, protection at the same time, speed control of seizures, maintain life-sustaining, prevention and control of complications, and actively look for the cause of treatment.
teachers: epilepsy continued state patients key to control seizures, multi-choice of strong, fast-acting anticonvulsant drugs.
At the same time as controlling seizures, keep the respiratory tract clear, oxygen supply (possible trachea intage or trachea inlet if necessary), physical cooling, rehydration to correct high permeable dehydration, pay attention to the prevention and control of infection.
attention to frequent convulsions caused by hypoxic cerebral edema of the brain, if necessary, can be given 20% glycol dehydration.
the convulsions stopped, sodium phenytoin can be given 80 to 100 mg/d, divided into three intramyal injections, sober after changing to sodium valproate.
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