Your next patient in general practice is a 9 year old boy, Troy. His step father comes with him because Troy has had frequent episodes of stopping all activity and staring at home and school for about 2-3 months.YOUR TASK IS TO:• Take a further history • Examine the boy• Explain the most likely diagnosis and management to the step father.HOPC:
For about 2-3 months the family noticed that Troy often stops all his activities and just stares into the air, not moving at all, attacks usually last for 5-10 seconds only and then he is immediately back to his normal state. There is no shaking or fitting, no jerky movements, no cyanosis, no incontinence, no post ictal episodes.
His school teacher observed the same behaviour and does not know what to think about it but it definitely influences Troy’s performance at school.
PHx.: normal pregnancy, delivery and development until now, no febrile convulsions, no illnesses, no operations, NKA.
FHx.: unremarkable
SHx: lives in a blended family with 1 younger step sister, whose mother actually died couple of years ago. Troy had initially problems to relate to his step father and step sister but things have settled quite well.
EXAMINATION:
General appearance normal, vital signs normal, neurological exam normal, all other systems normal.
DIAGNOSIS: absence seizures (previously called petit mal)
Absence seizures (also called petit mal or generalized nonconvulsive seizures) are a common paediatric genetic epileptic disorder. The seizures consist of multiple brief staring episodes with behavioural arrest that may recur hundreds of times daily without warnings. They are associated with generalized 3-hertz spike and slow wave discharges on electroencephalogram (EEG). Sometimes there may be eyelid flickering or fluttering, jerky movement of the face or fingers, lip-smacking or chewing (called complex absences).
There are known variants for example epilepsy with myoclonic abscences (EMA) and the Lennox-Gastaut syndrome (LGS) and myoclonic-astatic epilepsy (MAE) are more serious epileptic disorders in which children always have other seizure types, including tonic and atonic seizures, as well as developmental delay.
The prognosis for seizure remission differs for each syndrome. Childhood absence epilepsy (typical absence seizures with occasional generalized tonic-clonic seizures and an EEG pattern of generalized 3/sec spike and wave activity in a neurologically healthy child) has a reasonably good long-term prognosis with disappearance of seizures in the teen years.
Often attack can be evoked by hyperventilation.
INVESTIGATIONS:
EEG during an attack (can be evoked by hyperventilation or sleep deprivation)
MANAGEMENT:
1. Drug of choice- ethosuxamide (Zarontin)
2. Sodium valproate (!hepato toxicity!)
3. Clonazepam
4. Gabapentin
amc clinical exam 
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