Scenarios

Scenario 7: Epilepsy

Rory Heany is a 14-year-old boy who has been brought in to the emergency department following a seizure at home. He has a history of epilepsy for which he takes sodium valproate standard release tablets 1 g BD. He has been well prior to the seizure today and had not had a fit for several years prior to this seizure. His parents report that his behaviour has been very difficult over the past few days and that they suspect he has not been taking his regular medication. He also has a history of asthma but rarely requires his salbutamol inhaler (he uses a Metered Dose Inhaler 100 micrograms/puff) and does not take a steroid inhaler. When he arrives in the emergency department, he is no longer fitting but is still sleepy and appears to be post-ictal. His parents gave him some buccal midazolam at home because the seizure was continuing for several minutes. You admit him to the ward for observation and take blood for infection markers and valproate levels. He weighs 42 kg and has no known allergies. His details are as follows:

Hospital Number: 5673219

DOB: 1/2/2000

Address: Ty Fawr, Llanover, Monmouthshire NP7 8RU

• 1. Prescribe appropriate medications on his drug chart.

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  Correct answer:
  You should prescribe his sodium valproate on the regular side of the drug chart at his usual dose. You should also prescribe his salbutamol inhaler on the PRN section of the drug chart and a short-acting benzodiazepine on the PRN section of the drug chart in case he has a prolonged seizure whilst on the ward.

• 2. The valproate levels come back low and the infection markers are all normal. Rory later tells you that he hasn't been taking his medication for the past few days because he has been feeling very upset after splitting up with his girlfriend. He has been stable on the same dose of valproate for several years, and there is a clear reason for the low level so the dose is not changed. He has no further seizures and is discharged home the following day. Prescribe his TTA medications.

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  Correct answer:
  You need to make sure that he has an adequate supply of his regular medication, so it is sensible to send him home with sodium valproate. You also need to replace the midazolam that was used by his parents at home, so that they have an emergency supply should they need it again.
  
  Midazolam is a controlled drug, which means that certain aspects are required by law to be present on the prescription in order for the pharmacy to dispense them. They are as follows:
  
  Requirements for ALL prescriptions:

  • Should be written legibly in ink or otherwise so as to be indelible
  • Should be dated
  • Should contain the address of the prescriber
  • Should be indicated of the type of prescriber (doctor, nurse, pharmacist, etc.)
  • Should be signed in ink by the prescriber
  • Should state the name and address of the patient
  • Should contain the details of the age of the patient for children under 12 years
  • Should contain details such as name of drug, formulation, strength, quantity (in this case the formulation is oromucosal solution and the strength is 5 mg/mL).

  The additional legal requirements for controlled drug prescriptions are as follows:

  • Total quantity to be supplied in words and figures (in this case two prefilled 2-mL syringes).
  • Dose (in this case 10 mg as required; give one repeat dose after 10 minutes if seizure continues).