OSCE PREFINAL EXAMINATION

OSCE PREFINAL EXAMINATION

Date :2/12/ 2023

A 55yr old female resident of chityal with history of seizures 

Chief complaints:-

The patient was brought to casuality with cheif complaints of Active involuntary movements ,since 30 minutes, history of frothing from mouth deviation of eyeball upwards ,toungue bite with urinary incontinance no h/o of fever, head injury, vomitings, loose stools.

History of presenting illness - asymptomatic 20 yrs ago 

she developed sudden onset of movements in upper and lower limbs for 5 minutes , confusion 

The frequency & duration  of episodes were gradually increasing with in these 20 years 

Initially it was 1 episode in 5 yrs ---->later 2-3 episodes within 5yrs ----->one episode in 2years ---> single episode in 1yr ---->2-3 episode in a year 

PHENYTOIN -100mg OD was prescribed in a private hospital 

She was on underdosage of phenytoin  (phenytoin maintainence dose is usually 100mg thrice a day - 3-5mg/kg/day)

Even For which she noticed side effects like  frequent headaches, vomitings, gingival hyperplasia & constipation

EXAMINATION - patient was irritable and drowsy. Sensory and cerebellar examination is not elicited 

Deep tendon reflexes - elicited and normal 

Provisional diagnosis - status epilepticus 

Treatment 

  WHY LEVETIRECETAM IS USED OVER PHENYTOIN IN MANAGNENT OF STATUS EPILEPTICS

Phenytoin/fosphenytoin are recommended as a second-line treatment for status epilepticus; however, these drugs are associated with serious adverse events. Levetiracetam is expected to be as effective, but with less serious adverse events

However, serious adverse events associated with the use of FPHT, such as hypotension, arrhythmia and allergic reactions, are similar to those of phenytoin in the treatment of SE, during which it is crucially important to maintain circulation and respiration.The risk of these adverse events is increased in elderly patients or those with cardiac disease.

Levetiracetam (LEV), which primarily binds to synaptic vesicle protein and regulates the release of neurotransmitters, is considered to be effective for SE with less serious adverse events 

My understanding about treatment for status epilepticus 

Also besides side-effects other the considerable factors -  characteristic demographic and scientific RCT data interpreted below as:

Efficacy of levotirecetam v/s phenytoin 

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30724-X/fulltext

References I've used  -1) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30724-X/fulltext

2) https://journals.lww.com/md-journal/fulltext/2017/06230/efficacy_of_levetiracetam_versus_fosphenytoin_for.38.aspx

3)https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30724-X/fulltext

4)https://pubmed.ncbi.nlm.nih.gov/34284302/

Also learnt about other cases like 

community acquired pneumonia: auscultation-

characteristic difference between inspiratory and expiratory bronchial breath sounds (gushing & hollow sounds respectively) 

-Differential diagnosis of bull neck 

-In ckd patient - percussion of distended abdomen & shifting dullness