Inpatient Case Study: 16 year old with generalized tonic clonic seizures

Background

Chief Complaint: 16-year-old Caucasian male with epilepsy, on levetiracetam admitted to inpatient pediatric floor following treatment and stabilization in ED for status epilepticus

HPI:

• Presented to ED via EMS following 10 minutes of sustained, generalized tonic-clonicseizure activity. Treated with IV diazepam and loading dose of levetiracetam, after which seizure activity abated. Postictal phase persisted for 30 minutes in ED. No inciting cause identified.
• Had had no break-through seizure until approximately a month ago, when he started having two-three minute generalized seizures, self-resolving, five to six times/week.
• After approximately 30 minute post-ictal stage, patient was alert and oriented. On confidential assessment reported mild depression and previous history of suicidal ideation

PMH: Epilepsy, diagnosed at age 12 years. On Levetiracetam, well-controlled.

PSxH: None

Family History: History of depression in mother, otherwise unremarkable

Medications: Levetiracetam

Allergies: NKDA

Initial Vitals on arrival to floor: BP 114/70 HR 64 RR 14 SpO2 98% T 98.2F

ROS (pertinent positives/negatives): Break through seizures. No fever, cough, respiratory distress, no vomiting or diarrhea, no rash, joint pain or swelling. ROS otherwise negative

Social Hx: Gender Identity: non-binary; Pronouns: they/them; reports no history of drug/alcohol/tobacco use. Lives with parents and younger brother

Ask

Screen for tobacco use with every youth age 11+ at every clinical encounter.

* Products used may vary between communities. Visit the ACT module to view illustrations of common products.

Create a space for confidentiality & trust

Case Study Sample Dialogue: Part 1 of 4

Clinician: Do any of your friends or family use tobacco or other vaping products? Some of my patients use Sourin, JUUL, or Puff Bar.

Patient: My friends vape after school. And some kids in my school go to the bathroom between classes and do it.

Clinician: And what about you, do you ever vape?

Patient: Yeah, I vape sometimes.

Clinician: I appreciate you being honest and sharing that with me.

Counsel

Counsel all patients who use tobacco about quitting, regardless of amount or frequency of use.

Case Study Dialogue Part 2 of 4

Clinician: Can you tell me why you vape?

Patient: Lots of my friends were vaping and I was curious. Kind of helps with stress, I think. Not sure now.

Clinician: As your doctor, I care about you and I want to help you stay as healthy as possible. A lot of people think vaping helps with stress, but that’s probably not true. Nicotine addiction can actually be a source of stress. When your brain is used to having nicotine around, you can feel worse -sometimes stressed or anxious -when you aren't vaping.

Patient: Oh wow-I didn’t know that.

Clinician: Have you ever tried quitting before?

Patient: I’ve stopped for a week, but I couldn’t focus on school and felt very grumpy all the time.

Clinician: Interesting. Those are symptoms of withdrawal. That tells us that nicotine is starting to change your brain -that you're developing an addiction. I want to help you stay as healthy as possible. Quitting vaping is an important way to keep you healthy. Are you interested in trying again?

Patient: Yeah, I guess so.

Treat

Link youth to appropriate behavioral supports

Behavioral support & additional follow-up

Case Study Dialogue: Part 3 of 4

Clinician: I’m so glad you’re interested in quitting. If it's ok with you, I'd like to have you complete this quick form to help us understand how dependent your body is on nicotine.

Patient: Sure.

*Patient is determined to be moderately dependent*

Clinician: Based on your assessment, I think using a medication combined with some quit coaching will help you the most. The medication can help with withdrawal symptoms as your body gets used to not having nicotine around. The quit coaching can help you learn how to manage cravings and triggers. Is that something you'd be interested in

Patient: Yes.

Clinician: Let’s set a quit date in the next 2 weeks. What day would you like to start?

Patient: Can I start next week?

Clinician: Next week is great. The sooner you quit, the better it is for your health! Do you have a preference on receiving text, calls or using a web-based app for cessation support?

Patient: I think text is okay.

Clinician: Great. I’m going to connect you to a text program that will help encourage you as you’re quitting. You can text ‘QUIT’ to 47848. You will receive personalized text messages timed to your quit date.

Patient: Okay, thank you.

Nicotine replacement therapy (NRT) and adolescent patients

* A full fact sheet for NRT and Adolescent Patients can be found at www.aap.org/NRT

* Dosing guideline can be found in NRT and Adolescent Patients at www.aap.org/NRT

Case Study Dialogue: Part 4 of 4

Clinician: I’m going to prescribe nicotine gum to help you reduce the urge to vape and to help control those jittery withdrawal feelings you had last time.

Patient: How is nicotine gum going to help me if it has nicotine in it?

Clinician: The gum will give you a controlled amount of nicotine to stop the cravings, but won’t give you the rush you get from the vape pen. Also, the gum doesn’t have all the harmful chemicals that your vape pen has.

Patient: So it’s just like regular gum? How much do I chew in a day?

Clinician: It’s not like regular gum. You don’t keep chewing it. The proper way to use this medication is called the “chew and park” method. Place a piece of gum in your mouth and bite slowly until you taste a strong peppery taste or feel a tingling sensation. This means the nicotine is being released. Then, stop chewing and “park” the gum between your cheek and gums. When you don’t feel the sensation anymore, begin to chew until you notice the peppery taste, and then park again. You will repeat this for about 30 minutes, or until the peppery taste and tingling sensation are gone.

Patient: Okay, that makes sense.

Clinician: Its important you don’t forget to park the gum. If you continuously chew without parking, you may feel a stomachache, hiccups, or heartburn.

Patient: Okay thank you.

Clinician: I’m proud of you for making the decision to quit. Quitting can be difficult, but I know you can do it. Let’s arrange a follow-up appointment with your primary care provider in a week.

Patient: I would like that. Thanks.

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Additional case studies were developed to show the variations in clinical settings, common products, screening techniques, motivational interviewing, patient response, and clinician considerations. Please return to the home page to see additional case studies.