CNS/ WORKSHOP 1/CASE 1/Group Aand B by kannan

No.4 Pharmaceutical care issues

2015-03-04 06:22:10 UTC

1.IV lorazepam should be the drug of choice instead of IV diazepam. Besides that, when we are using Lorazepam we will eliminate DDIs between carbamezapine and Diazepam

2.Poor compliance of the patients

3.The dose of carbamazepine is too low/ insufficient as the patients is having seizure for 7 years,.

Qs 1: Identify the unfamiliar medical terms and abbreviations

2015-03-04 06:22:20 UTC

GTC = generalised clonic-tonic seizures
A&E = accident and emergency department
LOA = Lost of appetite
LOW = lost of weight
arthralgias = joint pain
SLE = systemic lupus erythromatus
HEENT = Physical examination of HEAD, EYEs, EARs, NOSE and THROAT
malar rash = refer to image
A/E = air entry (examined using stethoscope)
DRNM = dual rhythm no murmur
Ext = examination of extremities
ANA titer = titer of antinuclear antibody (diagnosis of autoimmune disorder)

3. Signs and symptoms]

2015-03-04 06:24:18 UTC

Loss of consciousness

Urinary incontinence

Muscle rigidity

Jerking movement

Tingling sensation

sudden feeling of intense fears/ joy

smacking your lips

rubbing your hands

making random noises

Move your arms arounds.

Q7 : What is partial seizure ? In AB's case, is it simple or complex partial seizures ?

2015-03-04 06:25:34 UTC

Partial seizure is seizure activity begins at a focal site in the cortex.

AB is having complex partial seizure. Because it is due to loss of consciousness.

Q8 : An additional dose of Diazepam (10mg IV) and a full loading dose of pheyltoin (1200mg IV) were given in A&E. Seizures were terminated. AB was then admitted to the medical ward. The pysician want to continue maintainence anticonvulsant therapy by IV route until oral meds can be given. Which option is appropriate for AB

2015-03-04 06:30:12 UTC

IV Ethosuximide is not suitable as it is used to treat absence seizure. And It is unavailable in Malaysia.

IV Phenobarbital is not suitable because it contains many side effects.

IV Carbamazepine is not suitable as it is unavailable in IV route.

IV pheytoin is suitable as the previous medications is usually used for the maintainence.

Qs 2: Identify the abnormal lab tests. What is their clinical importance?

2015-03-04 06:30:58 UTC

SrCr 212umol/L (normal: 53-106umol/L)
=> possible renal damage

Hct: 34 (normal 36%)
=> slightly lower than normal. not so significant

Plt: 45x 10^9/L (normal 150-400 x 10^9/L)
=> Thrombocytopenia

Total bilirubin 17.1 umol/L (normal 17umol/L)
=> slightly higher than normal. not so significant

RBC count 6.8 x 10^6 cells/mm (normal 3.5-5.5x10^6 cells/mm)
=> Possibility of polycythemia

ANA titre 1 : 480 (normal 1: 160)
=> positive for autoimmune disorder (systemic lupus erythromatus)

CBZ concentration lower than normal
=> below therapeutic window

Serum amylase higher than normal
=> possibility of pancreas inflammation

What is status epilepticus? Does the patient's conditions correspond to status epilepticus? How to treat?

2015-03-04 06:36:02 UTC

Status epilepticus is a life-threatening neurologic disorder defined as 5 minutes or more of a continuous seizure, or 2 or more discrete seizure without complete recovery of consciousness between seizures.
Yes, the patient's conditions do correspond to status epilepticus.
Treatment:
Emergency ABC
Maintainance of adequate brain oxygenation
Supportive care and antiepileptic therapy.

Question 10: How should AB's hematological status be monitored to prevent ADR of CBZ

2015-03-04 06:49:28 UTC

Answer is A and C : The reason for FBC is because CBZ can cause side effect like blood disorder (eosinophilia, leucopenia, thrombocytopenia, haemolytic anemia). And the pts is also having thrombocytopenia. So in order to begin the CBZ and maintain it in therapeutic dosage we need to do FBC monthly. Although in this case, the CBZ plasma concentration is 3mg/L, which is lower than the therapeutic range (6-12mg/L), in order to have adverse effect the dosage should be at least more than 9mg/L. It is still better to monitor the FBC.

5. Develop a care plan for the treatment of epilepsy in this patient.

marikannan — 2015-03-04 06:54:03 UTC

Firstly, gather information from the patient such as,

First aid, safety and injury prevention at home and at work

Lifestyle, leisure and social issues (including recreational drugs, alcohol, sexual activity and sleep deprivation)

Family planning and pregnancy

Psychological issues

and more....

2015-03-04 07:04:59 UTC

Q10:Which pharmacological option listed has not been helpful in treating on/off syndrome?

marikannan — 2015-03-04 08:30:27 UTC

c. cisapride

Q9

2015-03-04 08:40:13 UTC

Reason: Administration of full dose initially may result in increase side effects of CBZ. Hence, gradual increase in dose is advisable.

(http://www.neuro.org.my/pdf/Consensus%20Guidelines%20on%20the%20Management%20of%20Epilepsy%202010.pdf)