C.S. is a 17-year-old boy, who was brought to the emergency room by his high school football coach and two teammates. The patient had been practicing for Friday night's high school football game when clinical manifestations developed suddenly. It had been a very hot afternoon and all of the players were sweating profusely. When the offensive line positioned itself to run a final play from scrimmage for the afternoon, the patient fell to the ground and appeared to lose consciousness. His body stiffened with arms and legs extended. He suddenly let out a shrill cry and appeared to stop breathing for about 15 seconds. The coach removed his football helmet just before C.S. went into a series of violent, rhythmic, muscle contractions accompanied by hyperventilation. His eyes were rolling and his face became grossly contorted. Suddenly, the jerking movements began to ease up and progressively became less intense until they stopped all together. He then took a deep breath and the incident seemed to be over. The entire episode lasted approximately 3-4 minutes. C.S. woke up confused with no recall of the attack. However, he complained of a headache and extremely sore muscles.

The patient had complained to his mother that morning before school of a "lightheaded feeling," and she had strongly suggested that he consider skipping practice today. He dismissed the symptoms with, "I'll be fine" and "It will pass." Just before he left for practice, his mother asked him how he was feeling. He reported that he "was feeling fine and ready for a good practice."

In the emergency room, 45 minutes after the incident, the patient still could not remember the episode and reported that his first memory was that of finding himself flat on the ground with all of his teammates standing around him and Coach saying, "Are you okay, Big Man?"

• The patient's birth followed a normal pregnancy with good prenatal care
• Developmental milestones were all WNL
• No previous history of seizure activity
• To his recall, he has not had any recent infections (confirmed by mother)
• He has a history of one concussion while playing football 2 years ago
• Diagnosed with mild hypertension at age 15 for which he has been under the care of a physician, and taking a low dose of a mild diuretic

• Younger brother (age 12) was diagnosed with epilepsy (primarily complex partial seizures) at age 3
• Older sister (age 18) and father are alive and in good health
• Mother has osteoarthritis, which she treats with OTC NSAIDs PRN
• No other information on family history was obtained

Sodal History

• Denies drinking alcohol or taking any illegal recreational substances
• Reports doing well at school and at home with "no unusual stress in his life at this time"
• Denies tobacco use
• Plays offensive tackle for high school football team; was awarded "Offensive Lineman of the Year" honors in the conference last season
• Enjoys "fixing up his car" and "hanging out with friends"

• Reports feeling "weak and sleepy"
• There was no nausea, vomiting, bladder incontinence, or bowel incontinence during or after the incident

Medications

Hydrochlorothiazide 12.5 mg po QD

Allergies

NKDA

• Patient is a large, well-developed but obese white teenage male who is alert but tired
• He is in NAD
• He is wearing a football uniform that is moist from diaphoresis

Vital Signs

See Patient Case Table 41.1

• Warm, moist, and pale
• Face is flushed
• No lesions or abrasions

HEENT

• Atraumatic
• Pupils round and equal at 3 mm, responsive to light
• Conjunctiva pink but dry
• Visual acuity 20/20 bilaterally
• Fundi with sharp disks and no abnormalities
• Nasal mucosa pink but dry and without lesions or discharge
• Bite wounds on right lateral tongue and inside right cheek
• Tongue dry and rugged
• Pharynx dry with no exudate or erythema

• Neck supple
• Negative for thyromegaly, lymphadenopathy, JVD, and carotid bruits

Chest/lungs

• Lungs CTA throughout all lobes with no crackles
• Normal diaphragmatic position and excursion
• Chest expansion full and symmetric

Heart

• Apical pulse normal at 4th intercostal space, mid-clavicular line
• Regular rate and rhythm
• Normal S₁ and S₂ with no additional cardiac sounds
• Negative for murmurs, gallops, and rubs

• Soft, obese, and non-tender
• Liver percussion normal at 2 cm below right costal margin
• Negative for HSM, masses, and bruits
• BS present and normoactive

Genitalia/Rectum

Deferred

• Brisk capillary refill at 2 seconds
• Negative for edema, cyanosis, or clubbing
• Peripheral pulses 2 + and symmetric throughout
• Muscular hypertrophy of the upper extremities secondary to weight-lifting
• Full ROM

Neurologic:

• Oriented but slightly sleepy
• Cranial nerves II-XII intact
• Muscular tone and strength 5/5 throughout
• DTRs 2 + and symmetric
• Sensory intact to touch
• No motor deficits noted
• Able to perform rapid alternating movements smoothly and without error
• Negative for Babinski sign
• Cerebellar function and gait normal

See Patient Case Table 41.2

Normal

EEG

• Showed generalized background slowing
• No focal changes or epileptiform activity present
• Photic stimulation failed to induce changes in pattern

Clinical Course

While in the emergency room, the patient became progressively irritable and anxious and experienced a second seizure with sudden loss of consciousness and a generalized tonic convulsion that was closely followed by alternating clonic convulsions. The event lasted for approximately 3 minutes. The patient slept for 15 minutes after the seizure and awakened confused. He was treated with intravenous fosphenytoin to provide long-term seizure control, and his electrocardiogram was monitored for cardiac rhythm abnormalities (which are potential side effects when phenytoin is rapidly administered).

A second physical examination revealed a regular heart rate of 115, a regular and unlabored respiration rate of 20, and a blood pressure of 140/85. His lungs were clear to auscultation. His skin was diaphoretic, warm, and not cyanotic. The patient was sleepy and oriented to name only. A focused neurologic exam was essentially normal. Blood was drawn within 20 minutes after termination of the clonic phase of the seizure and submitted for a serum prolactin determination. The prolactin level was 462 ng/mL.

The patient was admitted to the hospital, monitored closely throughout the night, and continued on fosphenytoin. He did well with no further seizures. He continued to feel weak and tired but had no other adverse effects. He was discharged on the morning of the third day and referred to a specialist for further treatment.

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Abbreviations

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Abbreviations