Paediatric Neurology Clinical Letter

Paediatric Neurology Clinic Consultation Letter Medical Profile Global developmental delay Epilepsy, focal with secondary generalization Current Medications Levetiracetam 100mg BID Vitamin D supplement 400 IU daily Allergies Penicillin (rash) Relevant Investigations EEG (15/09/2024): Focal epileptiform discharges in the right temporal region. Brain MRI (01/10/2024): Mild cortical dysplasia in the right temporal lobe. Anthropometrics 4 years 6 months 18 kg (50th centile) 105 cm (75th centile) 52 cm (90th centile) Clinic Attendance It was a pleasure to review Peter Smith in my clinic. Peter's parents, Mrs. Sarah Smith and Mr. David Smith, were present during the consultation. A certified medical interpreter for Spanish was also present. Current Concerns / Medical Update Peter presents with concerns regarding an increase in seizure frequency and subtle changes in seizure semiology over the past month. His parents report that Peter Smith is now experiencing 3-4 brief staring spells per week, sometimes accompanied by automatisms like lip-smacking, in addition to his previously documented focal seizures. Peter's presenting complaint includes a recent increase in brief, 10-15 second episodes of unresponsiveness with lip-smacking, occurring predominantly in the mornings. These are distinct from his previously well-controlled focal seizures, which manifest as right-sided clonic movements. The parents note that the new episodes are not associated with any clear triggers and Peter recovers quickly, often resuming his play immediately. There have been no reported fevers or recent illnesses. His previous levetiracetam dosage had been effective in controlling the clonic seizures for the past 6 months. Peter has a known history of focal epilepsy. The current seizure activity consists of both the previously known focal seizures with right-sided clonic movements (frequency of approximately once every 2 weeks) and the new episodes of staring spells with automatisms (3-4 times per week). The new episodes are brief, typically 10-15 seconds, and are not associated with post-ictal confusion. Background Peter's past medical history includes a diagnosis of global developmental delay at 2 years of age. He was born at 36 weeks gestation via spontaneous vaginal delivery, with no significant perinatal complications. He has no history of hospital admissions for neurological issues prior to his epilepsy diagnosis at age 3. Surgical history is nil. Peter achieved sitting independently at 10 months, walking at 22 months, and spoke his first words around 2 years of age. He attends a special needs pre-school where he receives speech and occupational therapy. His fine motor skills are delayed for his age, and he communicates primarily through short phrases and gestures. Peter lives at home with both parents and an older sister, aged 7. His parents are both employed full-time. He attends pre-school five days a week. There is no smoking or substance use in the household. Family history is significant for a maternal uncle with febrile seizures in childhood. No other known neurological conditions in the family. His sister is healthy. Neurological Examination Vital signs: Temperature 36.8°C, Heart Rate 98 bpm, Respiratory Rate 20 bpm, Blood Pressure 95/60 mmHg. General physical examination was unremarkable. Peter Smith was alert and cooperative, making good eye contact. Cranial nerves II-XII intact and symmetrical. Motor function revealed good bulk and tone throughout, with mild hypotonia noted in the axial muscles. Strength was 4/5 globally in all four limbs. Deep tendon reflexes were 2+ bilaterally in biceps, triceps, patellar, and Achilles reflexes, with downgoing plantars. Sensation was grossly intact to light touch. Peter Smith demonstrated good coordination for his age during finger-to-nose testing. His gait was broad-based but steady, with no ataxia or significant asymmetry. Discussion Clinical assessment and working diagnosis with rationale: Peter Smith is presenting with new seizure semiology, suggestive of a change in his epilepsy pattern, possibly evolving focal epilepsy or a new seizure type. The brief staring spells with automatisms could represent focal aware or impaired awareness seizures, which have become more prominent. The mild cortical dysplasia on MRI likely represents the underlying cause of his epilepsy. His global developmental delay is a predisposing factor for epilepsy and will continue to require support. Differential diagnoses: Absence seizures, non-epileptic events (e.g., daydreaming, tics). Concerns raised by the patient or family and how these were addressed: Peter's parents expressed significant concern about the increased frequency of events and their impact on his learning and development. I reassured them that we will thoroughly investigate these new symptoms and adjust his treatment plan accordingly to regain seizure control. I acknowledged their concerns regarding school performance and discussed the importance of consistent communication between home and school. Patient or family education provided, including explanation of the condition, prognosis, and management: I explained to Peter's parents the likely nature of the new seizure type and how it differs from his previous focal seizures. We discussed the importance of continuing levetiracetam and the potential need for dose adjustment or adding another anti-epileptic drug. I also emphasized the chronicity of his condition and the importance of ongoing follow-up. I provided educational materials on epilepsy and seizure first aid. Safety advice and symptom monitoring guidance, including when to seek urgent medical attention: I advised Peter's parents to continue closely monitoring the frequency, duration, and characteristics of all seizure types. I instructed them to seek urgent medical attention if Peter experiences prolonged seizures (>5 minutes), clusters of seizures, difficulty breathing, or significant changes in his neurological status. Plan Investigations planned: Arrange an urgent repeat 24-hour video-EEG to capture the new seizure types and further characterize their electrographic correlate. Treatment plan, including medications, doses, and non-pharmacological management: I will increase Peter Smith's Levetiracetam to 150mg BID, with a review of seizure control in 2 weeks. I will also consider adding Clobazam if seizures remain poorly controlled after the Levetiracetam dose adjustment. Continue with current developmental therapies. Lifestyle or supportive advice: Encouraged parents to maintain a consistent sleep schedule for Peter and ensure a balanced diet. Provided information on local epilepsy support groups. Referrals to other specialties or services: Referral to developmental paediatrics for reassessment of his global developmental delay and consideration of further interventions. Follow-up arrangements, including timing and mode of review: I will review Peter Smith in my clinic in 4 weeks to assess his response to the medication adjustment and review the results of the repeat EEG. I will also be available for a telephone consultation in 2 weeks to discuss initial response to the dose increase.