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First seizure in adults

A seizure is a transient occurrence of symptoms and/ or signs
 due to abnormal or synchronous neuronal activity in the brain 
( ILAE- International League Against Epilepsy )

Estimated that about 10 % of the population would experience atleast one epileptic seizure ( 3 % risk of epilepsy ) In US about 150 000 adults present each year with an unprovoked first seizure ( less than ½ have a readily apparent cause ) WHO estimates that about 70 % of people with epilepsy could live seizure free if properly diagnosed and treated Despite a decrease in disease burden ( from 1990-2016 ) epilepsy remains an important cause of disability and mortality ( Lancet -Neurology Feb 2019 ) UK active epilepsy estimate is 5-10 cases/1000 ( NICE )

International League Against Epilepsy-ILAE recommends making a diagnosis of epilepsy if the patient meets 
any 1 of the following conditions-Atleast 2 unprovoked seizures occurring 24 hrs apart 1 unprovoked seizure and a probability of further seizures over next 10 yrs is greater than 60 % Diagnosis of an epilepsy syndrome

Provoked seizure –

Abnormal White Cell Count

White cell count abnormalities -assessment and evaluation

Monocytes- Constitute 3-8 % of the WCC Remain for a relatively short time in the circulation- after which they migrate to tissues and body cavities where they differentiate into macrophages They play a role in the inflammatory process ( members
of the mononuclear phagocyte system ) Good evidence exists to suggest that blood monocytes consist of several populations

Monocytosis –Associated with infection and inflammatory process Causes can be

○ Reactive monoytes
Infection- commonest cause
Inflammatory conditions as collagen vascular disease
chronic neutropenia
hemolytic anaemia
Haematopoetic and non Haemtopoetic neoplasms

○ Neoplastic Monocytes
several primary hematologic neoplasms harbor neoplastic monocytes including CMML ,

Facial pain

Dental-Usually acute presentation Unilateral Located within the mouth but sometimes may be difficult to localise More than 90 % of orofacial pain is dental in origin Usually severe and throbbing in nature Made worse by hot or cold food or drink or by biting on the affected side

Dental caries- common cause which can progress to infection of the pulp ,


Macrocytosis –An increase in the mean cell volume ( MCV) above the normal range 

 Upper range may be quoted as 95-100 fl. Prevalence ranges from 1.7 % to 5 % Up to 60-80 % with macrocytosis may not have anaemia

Main causes- Alcohol B12 and or folate deficiency Medications Hypothyroidism ( rarely ) Bone marrow dysplasias Liver disease ( non-alcoholic ) Reticulocytosis Physiological ( neonates ,

Antibiotics- types based on mechanism of action

Inhibit cell wall synthesis- beta lactams.

Natural penicillins
 Penicillin G Penicillin V Benzathine P Procaine P, Penicilllinase R
 Methicillin Nafcillin Cloxacillin Dicloxacillin Oxacillin , Amoxicillin Ampicillin ,Antipseudomonal penicillins
 Ticarcillin Pipercallin
also comes in combination with Tazobactam 
( Tazocin ) Carbeniclin

Cephalosporins – 1st Gen
 Cefadroxil Cephalexin Cephradine Cefazolin 2nd Gen Cefaclor Cefamandole Cefuroxime Cefoxitin 3 rd generation -Cefdinir Cefditoren Cefotaxime Cefpodoxime Ceftibuten Cefsulodin 
 Cefotaxime Ceftazidime Ceftriaxone Cefixime Cefoperazone Ceftizoxime Cefteram
,4th Gen

Cefozopran ,5th Gen Ceftaroline Ceftobiprole


Autism Spectrum Disorder-recognition and referral (Children )

Autism spectrum disorder is a complex developmental condition , behaviorally defined that includes a range of possible developmental impairments in reciprocal social interaction and communication , and also a stereotyped , repetitive or limited behavioral repertoire ( SIGN 2016 )

DSM -5 has created an umbrella term- ASD which now includes previously separately described conditions as-Autistic disorder ,Asperger syndrome,Childhood disintegrative disorder,Pervasive developmental disorders not otherwise specified,This reflects a better understanding of the matter ,


Delirium ( some times called ‘ acute confusional state ‘ ) is a common clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course 

Hyperactive type-heightened arousal restless agitated or aggressive hallucinations wandering. hypoactive type -Withdrawn Quite Sleepy Paranoid reduced conc and appetite.

Choosing an antidepressant

What is available and how does it work ? more than 
30 agents for unipolar depression

Most antidepressants work by enhancing the activity of monoamine neurotransmitters : serotonin , noradrenaline /norepinephrine or dopamine
 this is based on theories that implicate a deficiency of monoamines in the biology of depression popularly called the ”

Suicidal patient- assessment

Suicide can be defined as intentional self
 inflicted death

Suicide is a rare event Between 3.5 and 5 % of adults reported suicidal thoughts in the last year but only 0.5 % to 0.7 % actually made an attempt to end life ( US, UK date -BMJ 2017 ) In UK one in 5 adults has considered suicide at some time and one in 15 has attempted suicide Suicide prevention is a priority Approximately 6000 people take their own life each year in the UK ( NICE 2018 ) Patients would have sought help from health-care professions for eg
○ approximately 50 % of those who take their own lives will have seen a GP in the 3 months before death
○ 40 % in the month beforehand
○ around 20 % in the week before death

National Confidential Inquiry into Suicide and Safety in Mental Health October 2018
Few points to note
 Report looks at data from 2004- 2014 Suicide rate follow different patterns between countries and varies also within each country Highest rate is in men in middle age Crisis services providing an alternative to hospital admissions are an established part of mental health services now ( CRHT- crisis resolution / home treatment teams ) Commonest suicide method is hanging ,

Attention deficit hyperactivity disorder ( ADHD ) in children and young adults

Attention deficit hyperactivity disorder ( ADHD ) -A persistent pattern of inattention and/ or hyperactivity-impulsivity 
that interferes with functioning or development 
( American Psychiatric Association )

Known as hyperkinetic disorder in Europe and other nations that use the WHO classification system

How common – Most common behavioral disorder in childhood Neurodevelopmental disorder -childhood onset of symptoms and impairment Affects 8-12 % children worldwide
This may also vary depending upon criteria used for diagnosis Symptoms typically appear in children aged 3-7 yrs Rate of ADHD falls with age Prevalence increased Affects all sexes but is more common in boys
More commonly diagnosed in males Also affects adults Associated with poverty ,