A 25-year-old man with no past medical history comes to his primary care physician for follow-up after a seizure episode 1 week ago. According to his coworkers, he suddenly lost awareness and began having semi-purposeful movements of his right hand. A few seconds later, he fell and had generalized tonic-clonic movements of his arms and legs. The event lasted about 2 minutes and was followed by at least 20 minutes of confusion and lethargy. The patient woke up in the ambulance and had no memory of the event. He admits that 30 seconds before the seizure he had a feeling of uneasiness in his stomach. He has no history of similar events, head trauma, central nervous system infections, or family history of seizures. He takes no medications at home. He works as an accountant and does not use alcohol, tobacco, or illicit drugs.
His vital signs are within normal limits. Physical examination is unremarkable. In the emergency department, the patient had a normal laboratory workup, urine drug screen, and noncontrast head computed tomography.
Which of the following is the best next step in management of this patient?

Question

A 25-year-old man with no past medical history comes to his primary care physician for follow-up after a seizure episode 1 week ago.  According to his coworkers, he suddenly lost awareness and began having semi-purposeful movements of his right hand.  A few seconds later, he fell and had generalized tonic-clonic movements of his arms and legs.  The event lasted about 2 minutes and was followed by at least 20 minutes of confusion and lethargy.  The patient woke up in the ambulance and had no memory of the event.  He admits that 30 seconds before the seizure he had a feeling of uneasiness in his stomach.  He has no history of similar events, head trauma, central nervous system infections, or family history of seizures.  He takes no medications at home.  He works as an accountant and does not use alcohol, tobacco, or illicit drugs.
His vital signs are within normal limits.  Physical examination is unremarkable.  In the emergency department, the patient had a normal laboratory workup, urine drug screen, and noncontrast head computed tomography.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation (localized semi-purposeful movements, loss of awareness, tonic-clonic movements, and amnesia) is most consistent with a complex partial seizure that has generalized. Complex partial seizures are usually preceded by an aura (sensory symptoms). Unprovoked first seizures require neuroimaging studies to identify structural brain abnormality. Brain MRI is more sensitive than CT in identifying lesions such as cortical dysplasias, infarcts, or tumors. EEG may show abnormal waves but can also be normal after a seizure. Abnormal MRI or EEG after a single seizure indicates a high risk of future recurrent seizures. These patients benefit from antiepileptic drugs. Patients with normal studies have a lower risk of recurrent seizures and generally do not require drugs (Choices B and E). (Choice C) Continuous EEG monitoring is used primarily to detect nonconvulsive seizures, which were not seen in this patient. (Choice D) This patient's presentation is consistent with an epileptic event. He requires diagnostic testing to rule out underlying organic disease before assuming he had a psychogenic nonepileptic seizure. Educational objective: A single unprovoked seizure requires investigation with laboratory studies, MRI of the brain, and EEG to rule out underlying organic disease and estimate future seizure risk. Abnormal studies indicate a high risk of recurrence and usually require antiepileptics. __________ References: Considerations in the treatment of a first unprovoked seizure. (http://www.ncbi.nlm.nih.gov/pubmed/18777475) Risk of recurrence after a first unprovoked seizure. (http://www.ncbi.nlm.nih.gov/pubmed/18184149)

A 25-Year-Old Man with No Past Medical History Comes to His