OSCE and key learning points (prefinal examination)

 Following the case discussion of a 60 year old female who presented with active uncontrolled abnormal movements of the limbs, some questions which were discussed as part of the Objective Structured Clinical Examination are:

1. What triggers Status epilepticus in a patient with pre-existing epilepsy?

  There are many etiologies for status epilepticus including both obvious causes like non-compliance with the prescribed anti-epileptic medication (To be noted: the medication prescribed in the past for this patient was chronically underdosed) and other causes like:

• Cerebrovascular accidents
• Central nervous system infections
• Drug withdrawal syndromes (alcohol, benzodiazepines)
• Metabolic derangements (hypoglycemia)
• Hypoxia
• Head trauma
• Hypertensive emergencies
• Autoimmune disorders

In this patient it was noted that at the time of admission, patient had hyperglycemia (GRBS: 222mg/dL) which later normalized without the need for medical intervention.

 

The next question then becomes: Can hyperglycemia can be the cause of status epilepticus?

"Hyperglycemia-induced seizures are refractory to antiepileptic medications, account for 15–40% of seizures in patients with HHS, and are commonly focal motor seizures and epilepsia partialis continua" according to an article.

However, HHS or Hyperosmolar Hyperglycemic State is a life threatening complication of diabetes mellitus and this patient is not a known case of diabetes mellitus.

The question remains about the exact etiology of this particular episode of seizure that the patient presented with.

2. Comment on the therapeutic index of Phenytoin. In this case, can the fact that the anti-epileptic medication was chronically underdosed be considered medical malpractice?

According to another article published by National Institutes of Health, Phenytoin is classified as a NTI(Narrow Therapeutic Index) drug.

This means that the efficacy of Phenytoin as an anti-epileptic drug is limited to a narrow blood concentration beyond which it is lethal and below which it is ineffective. This explains why the patient kept experiencing seizure episodes over the years despite taking Phenytoin religiously for the past 23 years. 

Underdosing could be the cause of persistence of the seizures. In addition, the long term use of Phenytoin has led to Grade one drug-induced gingival overgrowth (DIGO) in the patient. 

In conclusion, Yes. The long term underdosing of Phenytoin to treat a case of epilepsy can very well be considered medical malpractice. Vigilance in the practice of prescribing drugs must be effected and drug dosages must be tailored to meet the specific needs of each patient. 

Furthermore, patients on long term medications must be encouraged to go to their clinician for regular follow ups to be monitored for adverse affects and treated appropriately.

3. Is central IV access necessary for managing a patient with epilepsy? 

IV access is crucial for treating epilepsy, especially in acute conditions like status epilepticus when IV Benzodiazepines are to be given immediately after admission. 

However, once the patient has been stabilized, the question arises about the duration of maintenance of central IV line due to the risk of infections and thrombophlebitis. 

In yet another article published by the National Institutes of Health' the results of several randomized clinical trials, cohort studies, case and control studies, descriptive and qualitative studies have indicated the following steps as sufficient to prevent phlebitis:

• Protocol monitoring and continuous evaluation: Records that show date of puncture, dressings used, professional performing the procedure, puncture locations, number of puncture attempts and such.
• Asepsis: Using alcoholic chlorhexidine at >0.5% or aqueous chlorhexidine at 2%. In case of hypersensitivity, iodine solution or 70% alcohol may be used.
• Involving the patient: in the choice of PVC (Peripheral Venous Catheter) and puncture site. Analyzing patient characteristics, medication prescribed, expected duration of treatment and other risk factors before opting a PVC. 
• Dressing: It is not advisable to bandage the site of the IV line. A sterile, transparent, semipermeable adhesive dressing may be used to improve visibility at the puncture site.
• Nursing interventions to treat phlebitis: Application of alternate hot and cold compresses to decrease edema, erythema and pain is advised. Other non pharmacological substances like sesame oil or chamomile extract maybe used in small amounts to provide relief to the patient.

4. Why was Ceftrioxone administered to this patient?

The patient was given Ceftriaxone prophylactically to prevent infections. However, according to a study done in 103 male patients undergoing transurethral surgery who were given Ceftriaxone as the sole antimicrobial, the drug was not particularly useful beyond the immediate post-operative period. 

In contrast, according to a certain other retrospective study, IV 1g of Ceftriaxone is recommended to be administered over at least 30 minutes. The total adverse event rate observed was 1 in 753 cases or 0.13%.

Thus, it can be left to the attending physician's discretion whether to administer the prophylactic dose of Ceftrioxone or not. The physician is expected to keep in mind patient characteristics, drug interactions and other risk factors while making a decision.

KEY LEARNING POINTS

1. In studying the management of this patient as part of the OSCE, I have learnt the value of doing the due diligence of looking up the latest research before administering any drug to patients, preferably on a regular basis.
2. The importance of doctors working as a team with nurses, paramedics and other hospital technicians to ensure smooth sailing of patient management and to avoid unnecessary confusion.
3. Documentation of every patient encounter on all levels (medical student, intern, post graduate, senior resident, and professor) with proper integration and regular case discussions, if done in a systematic and well-structured manner, can improve the quality of health care significantly even in rural settings.
4. The vertical and horizontal integration of medical subjects (General medicine with pathology and pharmacology, etc.) as prescribed by NMC, India is practically applicable and absolutely necessary for every medical student in order to increase the competence of future doctors.
5. Managing or assisting in the management of real-time patients and retrospective reviews are the two most effective methods to understand and practice clinical medicine.