Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in an Emergency Department. Your next patient is a 56-year-old male patient, Thomas Frank, who is coming in because of an episode of loss of consciousness. Please take a history and perform the relevant examination.
Patient History:
Thomas Frank, a 56-year-old male lorry driver.
Today 3-4 hours ago, you lost your consciousness while at home off work. You do not know what actually happened – unsure about any triggers. Still, your partner at that time noticed you started screaming loudly and stiffening up and shaking continuously on both sides. This has caused such a big scene! Your partner said you had fitted on the floor for around 30 seconds. This is your second time experiencing this; the last time was a day ago. However, you didn't see a doctor about this until now as your partner is very worried about you.
When you regained consciousness, you noticed you had urinated yourself, and there was blood from your sore mouth. There were no other injuries otherwise. You still currently do not feel right or back to your usual self. You are feeling a bit nauseous and have a mild generalised headache at the moment.
No Hallucination, Déjà vu/ Flashbacks, no slurring of speech, no vision abnormalities. You are unsure about weaknesses.
Ideas, Concerns, Expectations:
You think this might be a seizure. You are concerned about how this will affect your work as a lorry driver. You want to be seizure-free. You want medication for this.
Past Medical History:
Hypercholesteremia, high blood pressure, had a few previous 'ministrokes' in the past. No previous head injuries.
Drug History:
Amlodipine, Atorvastatin, Aspirin.
NKDA.
Family History:
Migraines run in the family. Also, strokes and heart problems.
Social History:
You live with your partner.
You drink around 10-20 units a week.
You smoke 10 cigarettes a day for 20 years.
You work as a lorry driver.
Examination Findings:
Suppressed Alertness.
Weakness of hand, arm or leg on one side of the body.
Tongue biting on both sides of the tongue.
Differentials:
Generalised tonic-clonic seizure/ epilepsy
TIA/ Stroke
Complex migraine
Investigations:
Bedside:
Observations
ECG – exclude cardiovascular problems
Bloods:
Baseline bloods + specifics e.g. glucose – hypo/hyperglycaemia –> provoking factors for seizures, FBC – infection?, U+Es including magnesium – electrolytes imbalance can cause seizures.
Imaging:
MRI / CT Head – structural lesion? e.g. tumour, bleeding, ischaemia…etc.
Special Test:
Consider Lumbar puncture – rule out CNS infection?
EEG
Management: