Week 2 - Seizure and ALOC

Question 1

Ms. Samantha Jones, a 20 year old previously healthy female is brought in by ambulance after a seizure and altered level of consciousness.

Take a history of this patient.

HPC:
• Shaking, eyes rolling back.
• Seen at ED post ictal, unresponsive to verbal stimuli, tactile stimuli - withdrawal only. GCS - E2V3M4.
• No previous history (unlikely epilepsy), no neck stiffness, no skin lesions, rash (unlikely meningitis).
• Limbs - hyperreflexia, 3+
• Upgoing Babinski (plantar reflex) bilateral.

Answer 1

HPC:
• Onset - how long ago did it happen?
• Alleviating factors
• Timing - experienced it before? How long did it last? 
• Exacerbating factors
• Severity
• Associated symptoms i.e. loss of consciousness, neck stiffness, skin lesions/rash, fever, photophobia, headache, neurological symptoms.
• Effect on lifestyle.

• Preceded by aura (subjective sensation), followed by postictal state (drowsy, confusion).
• Tongue biting, urinary incontinence.
• Drug use i.e. cocaine, ICE, tricyclics etc.
• Alcohol abuse.
• Head injury/trauma?
• Slow, progressive chronic morning headache, crescendo. Unilateral paralysis, vision defects, anosmia (brain tumour).
• Vomiting, bradycardia, papilloedema (raised ICP).

• IVDU, congenital heart defects, history of neurological disease.

PMHx:
• Past medical history of strokes/neurological disorders, epilepsy/seizures, cancer, CNS infection.

PSHx:
• Past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, Pneumococcal.

FHx:
• Family history of strokes/neurological disorders, epilepsy/seizures, cancer.

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, hands washed.
2. General inspection: level of consciousness, orientation to person, place and time, involuntary movements, facial symmetry, signs of trauma, deformity, speech.

3. Vital signs:
• BP.
• HR.
• RR.
• Temperature.
• BSL, BMI.

NEURO
Cranial nerves I-XII

Upper limb
1. General inspection - asymmetry, abnormal posture, muscle wasting, scars. Handedness, fasciculations, pronator drift.

2. Muscle bulk
3. Muscle tone - flexion/extension of wrist, supination/pronation at elbow, shoulder.
4. Muscle power
   • Shoulder - abduction (C5, C6), adduction (C6, C7, C8).
   • Elbows - flexion (C5, C6), extension (C7, C8).
   • Wrist - flexion (C6, C7), extension (C7, C8).
   • Fingers - flexion (C7, C8), extension (C7, C8), abduction (C8, T1), adduction (C8, T1).
5. Reflexes - hyperreflexia.
   • Biceps (C5, C6).
   • Triceps (C7, C8).
   • Supinator/brachioradialis (C5, C6).
6. Coordination - rapid alternating movements, finger nose test, rebound.
7. Pain
8. Position sense
9. Vibration
10. Light touch

Lower limb
1. General inspection - abnormal posture, involuntary movements, muscle wasting, fasciculations, scars. Gait (tandem, toe/heel walking), Rombergs test.

2. Muscle bulk
3. Muscle tone - passively flex/extend knee, flex/extend/invert/evert ankle, hip.
4. Muscle power
   • Hip - flexion (L2, L3), extension (L5, S1, S2), adduction (L2, L3, L4), abduction (L4, L5, S1).
   • Knee - extension (L3, L4), flexion (L5, S1).
   • Foot - dorsiflexion (L4, L5), plantar flexion (S1, S2), eversion (L5, S1), inversion (L5, S1).
5. Reflexes - hyperreflexia.
   • Knee jerk (L3, L4).
   • Ankle jerk (S1, S2).
   • Plantar reflex (L5, S1, S2).
6. Coordination - heel to shin, toe-finger test, foot-tapping test
7. Pain
8. Position sense
9. Vibration
10. Light touch

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Hypoglycaemia induced seizure.
• DDx:
- CVA/TIA - unlikely.
- Meningitis - possible however no neck stiffness or skin lesions.
- Encephalitis.
- Brain tumour.
- Drugs (cocaine, ICE, tricyclics etc.).
- Alcohol (withdrawal).
- Idiopathic - epilepsy (presenting for first time).
- Head injury.
- Metabolic disorder e.g. electrolyte abnormalities (Na+, Ca2+).
- Genetic disorder.
- Neurodegenerative disorder e.g. MS
- Narcolepsy.
- Vasovagal syncope (aura, migraine)
- Cardiac arrhythmia e.g. VT.
- Orthostatic hypotension.
- Vertigo.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC - WCC (CNS infection).
• U&E’s - electrolyte imbalance e.g. hypo/hypernatremia or uraemia.
• BSL - hyper/hypoglycaemia can cause provoked generalised tonic-clonic seizures.
• LFTs.
• Blood cultures.
• EEG.
• Toxicology screen.
• CT head - may reveal evidence of a structural lesion of other process that has caused the seizure.
• Serum prolactin.
• Serum CK.
• Lumbar puncture - normal or elevated WBC in infection.
• MRI brain - structural lesion may be present as a cause for seizure e.g. tumours, aneurysms.
• ECG, CXR.

Question 5

What treatment does this patient require?

Answer 5

• Termination of seizure activity and airway protection (basic life support).
• 100% oxygen delivered by nasal cannula or non-rebreathing mask.
• IV access - bloods (liver function, renal function, electrolytes, calcium, phosphorus, magnesium, FBC, toxicology, serum anticonvulsant medication levels).
• BSL.
• ECG, O2 sats, ABG.
• IV lorazepam. Midazolam → give more after 5 minutes. If doesn’t work after twice (resistance after 2 reasonable doses) → alternative - guidelines vary - ketamine, sodium valproate infusion, phenytoin, kepra, sedatives (propohol).
• Give 20-30g glucose IV e.g. 200-300mL of 10% dextrose. This is preferable to 50-100mL 50% glucose which harms veins. Expect prompt recovery.
• Glucagon 1mg IV/IM is nearly as rapid as dextrose but will not work in drunk patients.
• Dextrose IVI may be needed for severe prolonged hypoglycaemia.
• Once conscious, give sugary drinks and a meal.
• Patient cannot go driving or swimming anytime soon.