levonorgestrel, six capsules inserted subdermally in arm, irregular menstrual bleeding). Longer term preparations offer lower
cost over the duration of action (but greater one-time cost) and greater convenience.
Benefits of all the hormonal contraceptives: ABCDEs: Anemia reduced, often clears Acne; Benign breast disease and cysts
decreased;C ancer (ovarian decreased),C ycles regulated, IncreasedCervical mucous which reduces STDs;Dysmenorrhea
decreased, decreasesEctopic pregnancy rates and of course: virtually no chance of pregnancy when taken as directed (98-
Risks of hormonal contraceptives: slight weight gain is usual (5 lbs), increases risk of DVT especially in combination with
smoking, may stimulate estrogen-receptor positive breast cancers, but does not appear to cause them, may have to try two or
three different preparations to arrive at the one for the patient. Also note that hormonal contraceptives do not provide as much
protection against sexually transmitted diseases, compared to barrier methods.
Directions: Start OCP on the first day of the next menstrual period. Place package in an obvious location to help you to
remember. Take at the same approximate time each day. Use additional contraception for the first two months, as OCP
contraception is not reliable until then. If you miss a day, take two pills the next. If you miss two days, take two pills for the
next two days and use an alternative method until the next period. Give prescription for OCP of choice…any family members
(sisters/mother) on OCP? What works for them? Arrange follow up.
3. 16 year old boy with epilepsy documented by neurologist, comes to you because he does not want to see his parent’s
family doctor. Wants a driver’s license. Take a history and counsel.
History of seizure disorder: Patient ID. Age of onset (primary generalized rarely begin < 3 or > 20 years old). Precipitants:
Sleep deprivation, drugs, EtOH, TV screen, strobe, emotional upset. Describe seizures (Jacksonian march? Salivation,
cyanosis, tongue biting, incontinence, automatisms, motor vs. visual/gustatory/olfactory), frequency, duration, what body parts
affected and in what order (motor – frontal lobe, visual/olfactory/gustatory hallucinations = temporal lobe), promontory signs
(presence of aura: implies focal attack), post-ictal state (decrease in level of consciousness, headache, sensory phenomena,
tongue soreness, limb pains, Todd’s paralysis - hemiplegia), degree of control achieved with medications, at what dose and for
how long, corroboration from family if possible. Was a CT scan done when seizures were first diagnosed? Number and
description of recent seizures, are they different from previous seizures? Is the patient having any new symptoms such as
headache, morning vomiting, new neurological deficits. If the drug worked in the past why does the patient believe it isn’t
working now? Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias, peripheral
neuropathy, acne, nystagmus, dysarthria, hypertrichosis (excessive hairiness), gingival hypertrophy (phenytoin). Medications,
drugs and alcohol, smoking, allergies, past medical history, family history, review of systems.
Compliance: Is the patient taking meds? Why not? Problems at school or home? Ask about relationship problems.
Depression screen as in #19 above. Social supports.
Physical exam: neurologic exam including mini mental, cranial nerves, bulk, tone, power, sensation, cerebellar exam, deep
Treatment: Discuss importance of compliance with medication and avoiding dangerous activities such as driving until good
control is achieved. Ministry of Transportation regulations require 1 year seizure free before they will grant a driver’s license
in Canada. Inform the MOT of the patient’s seizure disorder if you have not already done so and inform the patient that this is
required by law. If alcohol is an issue, inform the patient that chronic alcohol intake may decrease blood levels of antiepileptics
(via increased liver metabolism), and excess alcohol intake can precipitate seizures by lowering the seizure threshold thereby
precipitating a seizure. It is generally recommended that the patient not drink at all. Fatigue and concomitant illness can also
lower seizure threshold. The patient should consult a physician before taking other medications, as they may also lower the
seizure threshold. The same is also true of sedatives, cocaine, amphetamines and insulin. Fatigue and other illnesses can also
lower seizure threshold, in addition to various other medications. If patient is having stress management, anxiety issues, he
may require further counseling. Outline a treatment plan consisting of: EEG, CT head, metabolic screen, medications (if not
done already), and follow up appointments. Get the parents involved if possible.
Send blood for serum Dilantin (phenytoin) levels if patient is on this already. If Dilantin levels are therapeutic, but the patient
is having severe side effects or poor seizure control, a second drug may be added (usually carbamazepine or valproic acid).
Discuss what to do in the event of seizure, counsel parents if possible. Bystanders are not to insert objects into the patient’s
mouth. Turn patient on his side while seizing. Call ambulance or take to Emergency if seizure doesn’t stop in 5 minutes.