Neurology Follow-Up Clinic Letter

Diagnoses

Confirmed diagnoses and relevant past medical history:

1. Focal impaired awareness epilepsy
2. Essential hypertension
3. Asthma

Medications

Current medications, doses and frequencies:

1. Levetiracetam 500 milligrams orally twice a day
2. Amlodipine 5 milligrams orally once a day
3. Salbutamol 100 micrograms inhaled as needed

Plan

Management items, including treatment, referrals, investigations and follow-up actions:

1. Increase levetiracetam to 750 milligrams orally twice a day
2. Arrange a repeat electroencephalogram
3. Check a full blood count, liver function tests, and urea and electrolytes
4. Review in the neurology clinic in six months

It was good to see you in the neurology clinic. You attended today for a follow-up of your focal impaired awareness seizures, which we first started treating four months ago. Since starting your medication, the frequency of these episodes has reduced from three times a week to roughly once every fortnight. You described a typical warning of a rising sensation in your stomach and an unpleasant metallic taste, followed by a brief period where you cannot respond to others. You also noted some mild irritability over the past month, though you feel this is manageable.

You confirmed that you have not had any generalised shaking episodes, tongue biting, urinary incontinence, or episodes of complete loss of consciousness since our last appointment.

Your partner, who attended the appointment with you, explained that during your episodes you appear vacant, fiddle repetitively with your clothing, and smack your lips for about one minute. They mentioned that it takes you roughly fifteen minutes to feel back to your normal self afterwards, during which time you are slightly muddled and tired.

As you know, you have a background of high blood pressure and mild asthma. You also reminded me that you had prolonged febrile convulsions when you were a toddler, and that your maternal aunt has a history of epilepsy.

You currently live with your partner and work from home as a graphic designer. You do not smoke tobacco, do not use recreational drugs, and have completely stopped drinking alcohol since your diagnosis. You have surrendered your driving licence to the Driver and Vehicle Licensing Agency as required and are currently not driving.

We reviewed your recent test results together. Your MRI scan of the brain showed mild scarring on the left side of the hippocampus, known as left mesial temporal sclerosis, with no other structural abnormalities. Your routine blood tests from two months ago, including a full blood count, urea and electrolytes, liver function tests, and thyroid function tests, were all completely normal.

Neurological Examination

On examination today, your blood pressure was 128/78 millimetres of mercury and your heart rate was 68 beats per minute. Your cranial nerves, including your eye movements and visual fields, were entirely normal. Examination of your arms and legs showed normal muscle tone, full strength, symmetrical reflexes, and intact sensation throughout. Your coordination and walking pattern were both normal.

Summary and Differential Diagnosis

Overall, your history, examination, and MRI scan findings confirm a diagnosis of focal impaired awareness epilepsy arising from the left temporal lobe, secondary to left mesial temporal sclerosis. Your seizure control has improved on your current treatment, although you are still experiencing occasional breakthrough focal seizures.

Management Plan

1. Increase your levetiracetam dose to 750 milligrams orally twice a day to help stop the remaining breakthrough seizures.
2. Monitor your mood closely, and contact your general practitioner or our epilepsy specialist nurse if your irritability worsens on the higher dose.
3. Have a blood test performed at your general practice in four weeks to check your full blood count, liver function tests, and urea and electrolytes.
4. Attend a repeat routine electroencephalogram, which I have requested today.
5. Continue to refrain from driving until you have been completely free of all seizures for at least twelve consecutive months.
6. Return to the neurology outpatient clinic in six months for your next review.