1. Tab. Lobazam (Clobazam) 10mg - 1-0-1 (morning and night)
2. Tab. Nediprole (likely Sodium Valproate / Valproic acid) - 1-0-0 (once daily)
3. Tab. Oxetal 450 (Oxcarbazepine 450mg) - twice daily (with 3 months noted)
4. Tab. Lamosyn (Lamotrigine) - with dosing (0-0-½ or similar titration)

Diagnosis: Seizure Disorder (Epilepsy)

Management Overview

Key Management Principles for Seizure Disorder in Women:

1. AED selection in females - Important considerations because:
   • Valproate has teratogenic risk (neural tube defects) - requires folic acid supplementation and counselling about pregnancy
   • Oxcarbazepine and Lamotrigine are relatively preferred in women of childbearing age
   • Enzyme-inducing AEDs (like Oxcarbazepine) can reduce efficacy of oral contraceptives
2. Monitoring:
   • Serum drug levels (especially Valproate)
   • LFTs and CBC (Valproate can cause hepatotoxicity and thrombocytopenia)
   • Weight monitoring (Valproate causes weight gain)
   • Bone mineral density (long-term AED use)
3. Lamotrigine titration: Started at low dose and titrated slowly to avoid Stevens-Johnson Syndrome (SJS) - this explains the gradual dosing noted on the prescription
4. Counselling points:
   • Avoid sleep deprivation and alcohol (seizure triggers)
   • Driving restrictions as per local law
   • Medication compliance - never stop AEDs abruptly
   • Folic acid 5mg/day supplementation (especially if pregnancy is planned)
5. Follow-up: EEG, MRI brain if not already done, to identify seizure type and etiology

Note: The "?" before "Seizure Disorder" on the prescription suggests the diagnosis was still being confirmed at this visit - further workup (EEG, neuroimaging) would have been recommended alongside starting empirical AED therapy.

Complete Clinical Summary - Pushpa, Female, ~46-51 years

Prescriptions Extracted

1. Elixir Neuro Care (Dr. Mukesh Kumar Shukla - Neuro & Brain Specialist)

• Burning sensation in head
• Altered behavior
• Loss of consciousness

1. Tab Rexipra Forte (Escitalopram 10mg + Clonazepam 0.5mg) - 1 tablet at HS (bedtime) | C 1-0-1½
2. Cap P. Brain D 75/20 HS (likely Pregabalin 75mg + Mecobalamin 20mg) - 1 cap at bedtime
3. Tab Rejunex CD3 (Methylcobalamin + Vitamin D3 + B-complex) - 1 OD morning

2. Elixir Neuro Care (Second Visit/Paper - same clinic)

1. Tab Rexipra Forte (Escitalopram + Clonazepam) - 1 HS, C 1-0-1
2. Cap P. Brain D 75/20 - 1 HS (Pregabalin + Mecobalamin)
3. Tab Rejunex CD3 - 1 OD

3. Lab Report Paper (Handwritten)

• Hb: 11.8 g/dL (mild anaemia)
• TLC: 6500 (normal)
• RBS: 110.8 mg/dL (normal)
• S-TSH: 1.082 (normal)
• B.P.: 120/80 mmHg (normal)

1. Tab Paracetamol 10mg (likely 500mg) - 1-1-1
2. Tab Naboqin / Nabolin MG 300 (likely Gabapentin 300mg) - BD
3. Tab Neurocalcion put OD (Neurobalmin) - 3 times a week
4. Inj/Tab something - once a week

4. Metro Rishidev Hospital, Varanasi

1. Tab Buproac (Bupropion?) 150mg
2. Tab Aspinol/Aspirin 75mg (low-dose aspirin)
3. Tab Rospido (Risperidone 1mg?) - 1-0-1
4. Cp Seedream (possibly Sertraline or similar) - OD

CONSOLIDATED DIAGNOSIS

Dissociative Disorder / Functional Neurological Symptom Disorder (FNSD)

• Anxiety/Depression (given Escitalopram prescription)
• Mild anaemia (Hb 11.8) contributing to fatigue and symptoms
• Peripheral neuropathy (Pregabalin, Mecobalamin use)

PROPER MANAGEMENT

A. Confirm Diagnosis First

B. Pharmacological Treatment

Key change from 2013: The diagnosis has evolved from "? Seizure Disorder" to "? Dissociative Disorder" - this means the AEDs from 2013 should be gradually tapered and stopped under neurologist guidance.

C. Non-Pharmacological (Most Important for FNSD)

1. Psychoeducation - Explain to the patient and family that symptoms are real but not caused by structural brain disease. The brain is "misfiring" - not damaged.
2. Cognitive Behavioral Therapy (CBT) - First-line treatment for FNSD/conversion disorder. Address underlying psychological triggers and stressors.
3. Physiotherapy - For any motor symptoms associated with episodes.
4. Trigger identification - Stress, emotional triggers, sleep deprivation.
5. Seizure first aid education for family - Safety during episodes, do NOT restrain, do NOT force anything in mouth.
6. Avoid unnecessary AED use - AEDs are not beneficial in PNES and carry side effects.

D. Red Flags to Watch For (Refer urgently if):

• New neurological deficit (weakness, speech change)
• Prolonged loss of consciousness (>5 min)
• Incontinence during episode (may suggest true seizure)
• Fever + altered consciousness (meningitis/encephalitis)
• Sudden severe headache ("worst headache of life")

Summary

Pushpa, 46-51F has a long-standing history (since at least 2013) of episodic loss of consciousness, altered behavior, and burning head sensation. CT brain is normal. The treating neurologist's current working diagnosis is Dissociative (Conversion) Disorder / FNSD, likely with comorbid anxiety/depression. Current management with Escitalopram + Clonazepam + Pregabalin is appropriate for symptom control. Video-EEG and MRI brain are essential next steps. CBT/psychological therapy is the definitive treatment. The old AEDs from 2013 should be reviewed and tapered.

Updated Diagnosis with Normal MRI Brain

• Brain tumor
• Stroke / cerebrovascular disease
• Multiple Sclerosis (MS)
• Encephalitis / meningitis
• Vascular malformations
• Mesial temporal sclerosis (a common cause of epilepsy)

Confirmed Working Diagnosis

Dissociative (Functional) Neurological Symptom Disorder

Most Important Remaining Investigation

Video-EEG (Simultaneous Video + Brainwave recording)

• If an episode is captured during EEG recording with no epileptiform activity = confirms PNES/Dissociative disorder
• If spikes/sharp waves are seen = true epilepsy
• Without Video-EEG, you cannot fully distinguish PNES from epilepsy

• Serum Prolactin level - draw within 20 minutes of an episode. Elevated (>3x baseline) in true tonic-clonic seizures; normal in PNES
• Psychiatric evaluation - PHQ-9 (depression), GAD-7 (anxiety), trauma history (ACE score)

Definitive Management Plan

1. Stop Old AEDs Gradually

2. Continue Current Medications (Appropriate)

3. Psychotherapy - THE Most Effective Treatment

4. Patient and Family Counselling

• "The brain scans are normal - this is good news, there is no damage"
• "The symptoms are real - we are not saying it is imaginary"
• "The brain is sending wrong signals - this can be treated"
• "Stress, emotional triggers, and past trauma can cause these episodes"
• "Medicines alone will not cure this - therapy is needed"
• "Do not rush to give medicines during an episode - keep her safe and calm"

5. Lifestyle Measures

• Regular sleep schedule (sleep deprivation worsens episodes)
• Stress reduction techniques
• Avoid social isolation
• Identify and manage personal/family stressors
• Regular moderate physical activity

6. Safety During Episodes

• Lay her on her side (recovery position)
• Clear area of hard objects
• Do not restrain her
• Do not put anything in her mouth
• Do not give emergency AEDs (like Diazepam injection) unless confirmed epilepsy
• Time the episode - if >5 minutes or unusual features, seek emergency care

Prognosis

• ~50-70% of patients have significant reduction in episodes
• Earlier diagnosis = better outcome
• Continued misdiagnosis and unnecessary AEDs = worse prognosis and more harm