How to approach a patient with hypertension (HTN) on Amlodipine (Amlodipine) and Telmisartan (Telmisartan), with a history of subdural hematoma (SDH) and seizure disorder on Levetiracetam (Levetiracetam), who experiences throat discomfort and forced exhalation when alone, which resolves in the presence of others?

Approach to Patient with Behavioral Symptoms, Hypertension, and Post-Neurosurgical History

This patient is presenting with conversion disorder or functional neurological symptoms manifesting as forced exhalation and throat discomfort that resolves in the presence of others, occurring in the context of controlled hypertension and stable post-subdural hematoma status on appropriate seizure prophylaxis.

Primary Assessment: Psychiatric vs. Neurological Etiology

The key diagnostic feature is the complete resolution of symptoms when others are present, which strongly suggests a functional/conversion disorder rather than organic pathology. 1

• The belief in "black magic" combined with symptoms that disappear with social presence indicates a culturally-influenced somatic manifestation of psychological distress 1
• Throat discomfort with forced exhalation that is context-dependent (alone vs. with others) does not fit any organic neurological or respiratory pattern 1
• True neurological symptoms from his subdural hematoma history or seizure disorder would not selectively resolve based on social context 1

Rule Out Organic Causes First

Despite the psychiatric presentation, you must exclude organic etiologies given his significant medical history:

Seizure-Related Considerations

• Levetiracetam at current dosing (assuming standard 1000mg daily for 1 year) may be suboptimal for seizure prophylaxis 2
• Recent evidence shows patients receiving >1000mg total daily dose (typically 1000mg twice daily) had significantly lower seizure incidence compared to 1000mg daily dosing (p=0.01) 2
• However, his forced exhalation behavior does not resemble focal motor seizures, absence seizures, or post-ictal phenomena 1
• If seizures were occurring, they would not selectively happen only when alone 1

Hypertension-Related Complications

• His blood pressure control on amlodipine/telmisartan combination should be verified, as this combination provides effective 24-hour BP control 3, 4, 5
• Hypertensive encephalopathy would present with headache, visual disturbances, altered mental status, or seizures—not isolated throat discomfort with forced exhalation 1, 6
• Neurological symptoms from hypertension do not resolve based on social context 1

Post-Subdural Hematoma Sequelae

• One year post-burr hole evacuation with only 2 pre-operative seizures suggests good recovery 1
• Late complications (recurrent subdural hematoma, hydrocephalus) would cause progressive symptoms, not intermittent context-dependent behaviors 1
• Obtain non-contrast head CT only if new neurological signs develop (headache, focal deficits, altered consciousness) 1

Specific Diagnostic Workup

Perform targeted evaluation to exclude organic disease:

• Neurological examination: Assess for focal deficits, cranial nerve abnormalities, or signs of increased intracranial pressure (papilledema on fundoscopy) 1, 6
• Blood pressure measurement: Verify adequate control (target <140/90 mmHg); severe hypertension (>180/120 mmHg) with symptoms would indicate hypertensive emergency 1, 6
• Serum sodium and glucose: Hyponatremia can cause neurological symptoms post-neurosurgery; hypoglycemia mimics neurological disease 1
• Levetiracetam level: If available, ensure therapeutic dosing, though levels don't always correlate with efficacy 2
• EEG only if: Clinical suspicion for non-convulsive seizures exists (altered mental status, confusion, automatisms)—not indicated for isolated behavioral symptoms 1

Management Algorithm

Step 1: Optimize Medical Management

• Continue current antihypertensive regimen (amlodipine/telmisartan) if BP is controlled, as this combination is highly effective and well-tolerated 3, 4, 5, 7
• Consider increasing levetiracetam to 1000mg twice daily (2000mg total daily dose) for improved seizure prophylaxis, given his history of post-traumatic seizures 2
• The increased dose shows reduced seizure incidence without increased adverse effects (anemia, leukopenia, thrombocytopenia) 2

Step 2: Address Functional/Conversion Symptoms

Once organic causes are excluded, treat as conversion disorder:

• Provide reassurance that no dangerous neurological condition is present 1
• Avoid reinforcing the behavior through excessive medical testing or dramatic responses 1
• Refer to psychiatry or psychology for cognitive-behavioral therapy, which is first-line treatment for conversion disorder
• Address cultural beliefs about "black magic" respectfully while reframing symptoms as stress-related physical manifestations
• Consider involving family members in education about functional neurological symptoms

Step 3: Long-term Seizure Prophylaxis Decision

Routine long-term anticonvulsant use beyond 1 year post-injury is not recommended 1

• He experienced only 2 seizures pre-operatively, over 1 year ago 1
• Consider tapering levetiracetam after discussion with neurosurgery, as prophylactic anticonvulsants beyond the acute period show no proven benefit and may worsen cognitive outcomes 1
• If continuing, maintain at optimized dose (1000mg twice daily) rather than subtherapeutic dosing 2

Critical Pitfalls to Avoid

• Do not order extensive neurological workup (repeat MRI, angiography, prolonged EEG monitoring) for clearly functional symptoms, as this reinforces illness behavior 1
• Do not abruptly discontinue levetiracetam without neurosurgical consultation, given his seizure history 1
• Do not dismiss cultural beliefs about "black magic" as this will damage therapeutic rapport; instead, acknowledge the distress while providing medical explanation
• Do not use phenytoin if changing anticonvulsants, as it is associated with worse cognitive outcomes compared to levetiracetam 1
• Avoid excessive BP lowering if adjusting antihypertensives, as rapid reduction can cause cerebral hypoperfusion in patients with prior intracranial pathology 1