The following scenarios are fictitious but similar to those experienced by real patients and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.
The following case studies, written by Dr Alix Rolfe, relate to her article Epilepsy in children and young people: what is the role of primary care?
Case 1: Isla, 5 Months Old
Isla has been brought in by her father. The baby was lying on her mat when she made some unusual movements—she bent forward, and then her legs and arms became very stiff. Her father says that she has done this a couple of times.
Isla was born at 40+3 weeks. She is a first child. She was born by elective caesarean section, and there were no complications at birth. She has had her scheduled reviews by the health visitor and GP, and no concerns have been raised.
Upon examination, Isla seems to be normal for her age. Her development appears to be at the expected level. Her weight, length, and head circumference are tracking along the 50th centile. There are no abnormal movements.
Questions for Reflection
- What are the important considerations in the patient’s history?
- What is your management plan for Isla?
How to Manage This PatientAbnormal movements in infants and children are a relatively common presentation in primary care. The underlying diagnoses can vary significantly, from normal movements and parental anxiety to an underlying epilepsy syndrome such as infantile spasms. Taking a thorough history is vital, and should include the antenatal course and birth. It is important to ascertain the exact nature of the movements; if possible, a video recording of them would be most helpful. These movements may be due to infantile spasms, in which case referral to paediatric neurology services is appropriate. Advise Isla’s father why this is being done, and give safety-netting advice about more prolonged seizures.
Case 2: Mohammed, 14 Years Old
Mohammed and his mother come to see you at the practice. Mohammed’s mother tells you that he has been struggling a bit at school. He has difficulty keeping up with the work, and is feeling low and anxious about going to school.
Mohammed was diagnosed with absence seizures at 10 years of age, and has been taking the anti-epileptic medication ethosuximide ever since. He is good at taking his medication, and has had no recent seizures. His family are very supportive.
Mohammed is systemically well, and a physical examination does not find anything concerning. He is quiet, with a flat affect, and can struggle to make eye contact. His mother is clearly very worried about him.
Questions for Reflection
- What are the most important parts of Mohammed’s history?
- What diagnoses should be considered in the consultation?
- What should the next steps be?
How to Manage This PatientIt is important to elicit Mohammed’s developmental and educational history. There is an increased incidence of neurodevelopmental diagnoses—such as autism spectrum disorders, attention deficit hyperactivity disorder, intellectual disabilities, and psychiatric disorders—in patients with epilepsy, and these should be considered. If a neurodevelopmental disorder is thought to be present, the patient should be referred for further multidisciplinary assessment. This is also true if the epilepsy is considered benign and/or well controlled. Mohammed should be advised to contact his local epilepsy nurse, as they may be able to access further sources of help and information for the patient, such as peer support opportunities, third-sector organisations, and online resources. In addition, his school may be able to provide further information and/or counselling. Cognitive behavioural therapy is an option for children with epilepsy and comorbid depression and/or anxiety. Prescription of a selective serotonin reuptake inhibitor may be considered by a child and adolescent mental health specialist.
Case 3: Anna, 16 Years Old
Anna comes to see you by herself at the practice. She says that she wants to discuss contraception, as she has been seeing her boyfriend for a few months, and so far they have just been using condoms.
Anna has been at the practice all her life. She was diagnosed with epilepsy at 10 years old, and has been on anti-epileptic medication ever since. She is known to have mild learning difficulties, but is at a mainstream school.
Anna is systemically well. She has a body mass index (BMI) of 24 kg/m2, and her blood pressure is 105/75 mmHg.
Questions for Reflection
- What issues should be covered regarding the need for contraception?
- What factors may influence your choice of contraception?
- Are there any other issues that you should consider addressing in this consultation?
How to Manage This PatientThere are a number of issues to be considered in this consultation. Although Anna is aged more than 16 years, it is important to ensure that she is aware of her actions and is not being coerced into a sexual relationship. It is often useful to enquire about the age of her partner. The choice of contraceptive will be guided by the patient’s preferences and her personal, family, and social history. It is important to know whether there are significant risk factors that may influence the choice of contraceptive, especially the suitability of hormonal contraception. It is very important to know what anti-epileptic medication Anna takes, and if this needs to be reviewed by her epilepsy team. For example, female patients of child-bearing age should not be prescribed sodium valproate unless there are exceptional circumstances. It may be useful to discuss the use of hormonal contraception with the practice pharmacist. Routine enquiries about depression and anxiety are also recommended.
Case 4: Stefan, 18 Years Old
Stefan comes to see you by himself. He has just joined the practice because he has moved to the area to attend the local university. He says that he needs his epilepsy medication.
Stefan was diagnosed with epilepsy at 7 years of age. His epilepsy has been well controlled on sodium valproate; however, about 9 months ago he had his first seizure in 2 years. He had been less compliant with his medication, and the seizure happened after he had been out drinking with his friends. He was seen by the accident and emergency department and reviewed by his epilepsy team, and has been more compliant since then. He is otherwise well, and takes no other medication.
Stefan is systemically well, and has a BMI of 22 kg/m2. He takes regular exercise, and has joined the university hockey team. He is studying marine biology. He admits to drinking most weekends, and lives in the university halls of residence.
Questions for Reflection
- What are the important issues relating to Stefan’s epilepsy?
- How can his transition from paediatric to adult services be facilitated by the GP?
- What other issues should be considered by the GP?
How to Manage This Patient
Adolescence and the late teenage years can be a challenging time for patients with epilepsy, and the transition from paediatric to adult services can be difficult. These young people are likely to be going through many changes in their personal lives and, as they approach the end of school, they may be tempted to enter into more high-risk behaviours, such as alcohol consumption and/or illegal drug use. They are also less likely to engage with health services. At this consultation, it is important to ensure that Stefan will have his epilepsy care reviewed by local adult services, and that the transition will involve both his paediatric team and adult services, if possible. The process of transition should have already been discussed with him. It is also important to ensure that Stefan knows how to access medical services, and how to order and collect his medication. Advice regarding the effects of alcohol, drugs, and tiredness on his epilepsy should be provided, and the consultation should also cover the potential risks of living away from home, including issues related to bathing, watersports, and heights. Sudden unexpected death in epilepsy should have been discussed with Stefan and his family at the time of diagnosis, but it may be worth checking this. While waiting for the transition to occur, it may be useful to signpost Stefan to helpful websites and charities, such as Epilepsy Action (epilepsy.org.uk) or the Epilepsy Society (epilepsysociety.org.uk).