CASE 1 : Breakthrough Seizure d/t Non-compliance to Anti-epileptic with U/L Recurrent Post-stroke Epilepsy and HPT

Admission Day - Day 1 (3/3/14)

This 67 year old Malay man, with underlying hypertension, a history of CVA and recurrent post-stroke epilepsy since 2013, presented to the hospital following 2 episodes of generalized tonic-clonic seizure he experienced at home 30 minutes prior to admission. Although on daily medications for his epilepsy, he had not taken his anti-epileptic drug for days before his fitting episode. He is an active smoker who has smoked for about 50 years with an average of 40 sticks/day. When first seen in the hospital, he was confused, disorientated, tachypnoeic and afebrile. His GCS was 12/15 and spO2 was 95% under room air and he was put on oxygen supplementation via nasal prongs. Neurological examination showed no neurological deficits caused by his prior CVA or his current seizure episode. Investigations showed a low serum calcium of 2.09 mmol/L, low serum inorganic phosphate of 0.77 mmol/L and a plasma glucose reading was not available. He was diagnosed to have a breakthrough seizure due to non-compliance to medication and was started on IV Diazepam and IV Normal Saline. He was also given T. Phenytoin, T. Acetylsalicylic acid, and T. Simvastatin. Strict fit charting and GCS monitoring were observed. A CT brain was to be done if there is a further fall in GCS. 

Day 2 (4/3/14) 

Currently, patient is comfortable and his GCS has improved to 15/15. He slept well and had passed motion once. Vital signs were stable and physical examination revealed no positive findings. SpO2 levels had improved to 98% under room air and nasal prongs were removed. His IV fluids were also removed. A plasma glucose level was still not performed and there is no repeat blood test for his low serum calcium and inorganic phosphate levels. Upon asking, patient denied having done any CT brain earlier. No CT brain was ordered for this admission. Current medications is continued.

Day 3 (5/3/14)

Patient was seen by Dr P'ng and allowed for discharge. Vital signs were stable. Patient and his daughter were explained the importance of compliance to his medications. He was discharged with T. Phenytoin, T. Acetyl Salicylic acid, T. Simvastatin and a follow-up appointment on 1/4/14 to review his Therapeutic Drug Monitoring (TDM) Phenytoin test results. The final diagnosis made was breakthrough seizure due to non-compliance to medications with underlying CVA, recurrent post-stroke epilepsy and hypertension.