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Reflect on the case below and discuss whether or not you agree with the preceptor’s assessment and diagnostic impression of the patient, and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.): Subjective: CC (chief complaint): “My primary care physician sent me here for an evaluation because I am having seizures and my husband has noticed that they have increased in the last several weeks.” HPI: A.G. is a 66-year-old female referred to the clinic by her primary care physician for medication management due to increasing episodes of psychogenic non-epileptic seizures (PNES). Her spouse reports a noticeable increase in both the frequency and intensity of these episodes, which are a new development for A.G. The patient’s spouse is notably concerned, emphasizing the importance of addressing both A.G.’s and his mental health, fostering family support, and reinforcing understanding of PNES. Substance Current Use: M.P. denies use of tobacco, alcohol, or recreational drugs. Medical History: A.G. has a medical history of PNES, leading to a recent referral for medication management due to an increase in seizure frequency and intensity. Current Medications: She takes Atenolol and hydrochlorothiazide for hypertension, acetaminophen and ibuprofen for arthritic pain, and over-the-counter multivitamins. Allergies: No known allergies to food or medications Reproductive Hx: Transitioned into menopause at age 52 with typical symptoms such as hot flashes and mood swings. ROS: GENERAL: Reports episodes of fatigue following seizure-like episodes. No significant weight loss or gain reported. Experiences anxiety related to her condition. HEENT: No headaches or visual disturbances reported. No hearing changes or tinnitus. No nasal congestion, sore throat, or other ENT symptoms noted. SKIN: No rashes, itching, or significant changes in skin appearance. No bruising or lesions associated with seizures. CARDIOVASCULAR: No chest pain or palpitations. The patient has a history of hypertension. RESPIRATORY: No shortness of breath or persistent cough. No history of asthma or other chronic respiratory conditions. GASTROINTESTINAL: Regular bowel movements; no constipation or diarrhea reported. No nausea or vomiting. Reports normal appetite. GENITOURINARY: No dysuria, frequency, or incontinence. Normal for age, no history of recurrent UTIs. NEUROLOGICAL: The patient’s main concern is seizure-like episodes without actual epileptic activity. No memory loss or cognitive impairment besides anxiety-related symptoms. No history of migraines. MUSCULOSKELETAL: Has a history of arthritis. Reports of occasional muscle tension possibly related to anxiety. HEMATOLOGIC: No history of anemia or clotting disorders. No recent bruising or bleeding episodes. LYMPHATICS: No lymph node enlargement or pain reported. ENDOCRINOLOGIC: No recent changes in polyuria, polydipsia, or polyphagia. No thyroid symptoms such as heat or cold intolerance. Objective: Diagnostic results: The patient had undergone an electroencephalogram (EEG) to rule out epileptic seizures, as well as video EEG monitoring to capture the events in real-time. She was referred to psychiatry for an assessment to identify any underlying psychological factors contributing to the seizures. Assessment: Mental Status Examination: A.G. presented as her stated age, showing no signs of physical decline or aging beyond her years. She was appropriately dressed and maintained adequate hygiene, reflecting a level of self-care and awareness of social norms. During the evaluation, A.G. was cooperative, indicating her willingness to engage with the clinician; however, her underlying anxiety may have affected her overall demeanor. Visibly anxious, she exhibited signs of hyperarousal or distress, although specific behaviors related to this anxiety, such as fidgeting or avoidance of eye contact, were not explicitly noted. A.G. described her mood as “overwhelmed” and “distressed,” with an affect that was anxious and occasionally tearful, indicating a strong congruence between her expressed mood and observable emotional state. Her speech was normal in rate and tone, yet it conveyed significant worries about her condition, likely focusing on the implications of her ongoing seizures. A.G.’s thought processes were logical and coherent, suggesting clarity in her thinking; however, they were frequently marked by fear concerning her health, reflecting a possible fixation on her symptoms. Importantly, there were no signs of delusions or hallucinations, indicating a stable perception of reality. Diagnostic Impression: Primary Diagnosis: Psychogenic Non-Epileptic Seizures (PNES) ICD-10 code F44.5 Rationale: History and Diagnosis of PNES: A.G. has an established history of PNES, as her primary care physician’s referral specifically mentions PNES for seizure management. PNES are episodes that resemble epileptic seizures but do not involve abnormal electrical activity in the brain. They are often related to psychological distress rather than neurological dysfunction. EEG Results and Video Monitoring: The diagnostic results, including a clear EEG and video EEG recordings, rule out epileptic seizures. This confirms that the episodes are non-epileptic and likely psychogenic in origin. Psychological Factors and Mental Health Assessment: The mental health examination highlights significant anxiety and distress. Her mood is described as “overwhelmed” and “distressed,” which aligns with the psychological stress often associated with PNES. The psychiatric referral to assess underlying psychological factors supports this. Absence of Substance Use: A.G. denies the use of tobacco, alcohol, or recreational drugs, eliminating these as potential contributors to her symptoms. Exclusion of Other Medical Conditions: There is no evidence of other neurological conditions, such as epilepsy, given the normal EEG. Her cardiovascular, respiratory, and gastrointestinal systems show no abnormalities that might contribute to seizure-like activities. Rule Out Differential Diagnoses: Epileptic Seizures: Ruled out due to normal EEG findings and lack of clinical signs consistent with epilepsy. Substance-Induced Seizures: Ruled out due to the lack of substance use history in the patient’s profile. Other Medical Conditions, such as metabolic issues or cardiac problems: A.G.’s medical assessments have not revealed abnormalities in these areas that could explain seizure-like activities. Conversion Disorder: While PNES can be seen as a type of conversion disorder where psychological distress manifests as physical symptoms, the focus on PNES integrates both epilepsy exclusion and associated psychological distress more directly. Pertinent Positives: Established diagnosis of PNES and recent increase in frequency/intensity of episodes. Significant anxiety and psychological distress are evident in the mental status examination. Clear EEG and video monitoring findings consistent with non-epileptic events. Pertinent Negatives: No evidence of epileptic seizures or abnormal brain activity. Denies use of substances that could induce seizure-like activity. No other significant medical condition was identified contributing to the episodes. In summary, A.G.’s diagnosis of PNES is supported by both clinical and diagnostic findings. Her psychological distress appears to be a significant contributing factor, with her anxiety potentially exacerbating the frequency and severity of the episodes. The treatment plan should thus focus on addressing her anxiety and providing psychological support to manage PNES effectively.

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