Case Study 1: Seizure during a Final Exam

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 1: Akbar—Seizure during a final exam

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A 24-year-old man is brought into the ER after a witnessed tonic-clonic seizure during a college final exam. He is tachycardic and appears mildly somnolent and disoriented. He does not remember the seizure and was confused as to how he ended up on the floor of the classroom.
He has no history of seizure or other neurologic disease, but he does endorse depression, for which he has been on bupropion for ~7 years. He denies using any substances recently, including ETOH. He drinks a few cups of coffee per day—“more during exam weeks”—and says he may have had an extra cup this morning. The patient is somewhat tearful about being brought into the ER, and worries he will fail his final after “staying up all night to study.”

Question

What was the most likely trigger of his seizure?

The caffeine, bupropion, and sleep deprivation are all possible causes of seizure. However, his caffeine use did not change dramatically prior to the patient’s presentation, and he has been stable on bupropion for many years. Most likely, the sleep deprivation was a major driver of the seizure. This is a very common clinical scenario around university campuses.

follow-up Questions

This patient has several triggers for his seizure. Given that he has no other “red flags” on history or physical exam, a basic evaluation with a CBC, CMP (including calcium and magnesium), toxicology screens, an EKG, and neuroimaging will rule out most underlying causes. An EEG may not be appropriate at this point if he recovers completely within a relatively short period of time (brief seizure and recovery in minutes to hours). Anti-seizure medication is not always indicated after a single seizure with triggers and this patient would probably not be treated with long-term medication at this time. Consult state requirements regarding driving restrictions.

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