Maria, a 25 year old management consultant presents to A&E after having a “fit”. Four hours ago, whilst at work, Maria lost consciousness, fell to the floor and was observed to be having “jerky movements all over the body” by colleagues. The emergency services were contacted but the movements ceased spontaneously after 4 minutes. She regained consciousness while in the ambulance and was brought into the Accident and Emergency department in a state of confusion with a GCS of 10/15 (E2, V3, M5).
Her observations are:
Temperature: 37.9 C, Cap Refill: < 2 secs
BP: 109/71, HR: 88
RR: 14, Sats: 98%
A: Airway clear
B: Air entry bilaterally, no crepitations or wheeze.
C: Warm peripheries, good colour, Heart Sounds Normal (I + II + 0)
D: Pupils: PEARL, GCS: 10/15 (E2, V3, M5). BM : 4.6 mmol/L
E: No obvious trauma/bleeding. Abdomen soft, non-tender, no masses/guarding/rebound, normal bowel sounds present.
A few hours later her GCS has improved to 15/15 but she states that she is “exhausted and doesn’t have any memory of what happened after she arrived at the office this morning.”
You are an FY1 in the Accident and Emergency and have been asked to assess Maria by the on call Registrar.
Question 1: What other information in the history would aid in your assessment of Maria?
Further history reveals:
Maria is extremely distressed that she has involuntarily passed urine (incontinence) during the fits. She also has a very painful tongue with bite marks on the right side, which she does not remember doing.
Upon further questioning, in the moments leading up to her losing consciousness, the colleague had noticed that Maria kept “patting the side of her face with her right hand” and did not respond to her name. At the time, she was in a meeting where she was to due to give a presentation in front of the firm partners for the first time.
Upon questioning Maria, she mentions that she did not get much sleep over the last 2-3 nights.
In her past medical history, she has had one episode of febrile convulsions at the age of 3 and one “previous fit” at age 11 on the first day of secondary school. As a teenager she suffered depression for 2 years. She is otherwise fit and well.
She takes the Combined Oral Contraceptive Pill but says she doesn’t “always remember to take it”. Often, she takes paracetamol for headaches, but no other medication or alternative therapies. She has no known drug allergies.
Her mother’s sister, who lived with her through her during her childhood had epilepsy. She is one of 4 siblings. She did not know her father, and describes her relationship with her mother and siblings as “strained”. Maria has never been pregnant.
Maria recently got engaged and lives in a flat with her fiancé in central London. She describes her work as “a constant source of stress and anxiety”. She does not smoke or take recreational drugs but admits that over the last 6-8 months she has been drinking heavily on a daily basis, regularly going through a bottle of wine each evening. Her fiancé forced her to stop drinking and emptied the house of alcohol, where she has been working, in the days leading up to the presentation.
Question setter: Adil N. Ahmad (Final Year Medical Student, Peer-Assisted Learning SSC, UCL)
Experts: Dr Chris Turner, Consultant Neurologist & Dr Rebecca Redwood, Neurology ST5, National Hospital for Neurology, UCLH
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