A 16-year-old boy is brought to the emergency department by his mother after a single episode of generalized tonic-clonic seizure. The patient has been staying up late studying for midterm exams and has been feeling "more tired than usual" for the last few days. For the last 6 months, he has had occasional jerking arm movements in the morning but was not medically evaluated as they were brief and he otherwise "felt fine." The patient has had no recent fevers, vomiting, or headaches. He does not use alcohol or illicit drugs. His mother describes him as "anxious," but he has no chronic medical conditions and takes no medications. Temperature is 37.2 C (99 F), blood pressure is 120/60 mm Hg, and pulse is 72/min. On physical examination, the patient is drowsy but responsive to commands and oriented to person, place, and time. Cardiac examination reveals a regular rate and rhythm without murmurs. Cranial nerves II-XII are intact; there are no focal deficits. Deep tendon reflexes are normal in the upper and lower extremities, and plantar responses are flexor. There are no rashes or petechiae. Electroencephalogram shows bilateral polyspike and slow wave discharges.
Which of the following is the best next step in management of this patient's condition?

Question

A 16-year-old boy is brought to the emergency department by his mother after a single episode of generalized tonic-clonic seizure.  The patient has been staying up late studying for midterm exams and has been feeling "more tired than usual" for the last few days.  For the last 6 months, he has had occasional jerking arm movements in the morning but was not medically evaluated as they were brief and he otherwise "felt fine."  The patient has had no recent fevers, vomiting, or headaches.  He does not use alcohol or illicit drugs.  His mother describes him as "anxious," but he has no chronic medical conditions and takes no medications.  Temperature is 37.2 C (99 F), blood pressure is 120/60 mm Hg, and pulse is 72/min.  On physical examination, the patient is drowsy but responsive to commands and oriented to person, place, and time.  Cardiac examination reveals a regular rate and rhythm without murmurs.  Cranial nerves II-XII are intact; there are no focal deficits.  Deep tendon reflexes are normal in the upper and lower extremities, and plantar responses are flexor.  There are no rashes or petechiae.  Electroencephalogram shows bilateral polyspike and slow wave discharges.
Which of the following is the best next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c191_a1ea_8f63_31053c105fc1_MD0005_00 Juvenile myoclonic epilepsy (JME) is a common pediatric epilepsy syndrome that usually presents in otherwise healthy adolescents. In about one-third of patients, JME begins with absence seizures (eg, staring spells) up to 5 years before other seizure types. During adolescence, the classic presentation involves myoclonic jerks of the arms within the first hour of waking that can be aggravated by sleep deprivation and alcohol intake. Generalized tonic-clonic (GTC) seizures occur later in the disease course in almost all patients and may be the event leading to diagnosis. Up to half of patients have a concomitant psychiatric diagnosis (eg, anxiety). Electroencephalogram (EEG) classically demonstrates bilateral polyspike and slow wave discharges during the interictal period. Neuroimaging (eg, MRI) is typically normal and not needed for diagnosis when the clinical presentation and EEG are classic for JME. Valproic acid is the first-line treatment for all types of JME, and patients should be educated on sleep hygiene and avoidance of other precipitants. (Choice A) Although observation and reassurance are appropriate for a first unprovoked seizure, this patient's GTC seizure was preceded by multiple morning myoclonic seizures. Seizure recurrence is expected with JME, and antiepileptic therapy should be initiated without delay. (Choice B) Meningitis can cause seizures and is confirmed with lumbar puncture; however, this patient's lack of fever, headache, and nuchal rigidity makes meningitis unlikely. (Choice C) Infantile spasms are an epileptic disorder of infancy characterized by symmetric spasms, developmental delay, and hypsarrhythmia on EEG. Corticotropin (ACTH) and vigabatrin are the gold-standard treatments for infantile spasms but have no role in the treatment of JME. (Choice D) Ethosuximide is the first-line treatment for typical absence seizures but is not effective for GTC seizures. Educational objective: Juvenile myoclonic epilepsy should be suspected in healthy adolescent patients with upper extremity morning myoclonus and subsequent generalized tonic-clonic seizures. Electroencephalogram classically demonstrates bilateral polyspike and slow wave discharges during the interictal period. First-line treatment is valproic acid. References: Management of juvenile myoclonic epilepsy. (http://www.ncbi.nlm.nih.gov/pubmed/23756489)

A 16-Year-Old Boy Is Brought to the Emergency Department by His