The devil is in the detail (part 2)

Questions?

1.What additional information do you need and where can you get it?

What you really need is a witness account. This patient, with the best will in the world, can’t tell you enough to be getting on with.

The particular patient (true case, folks) came alone. I got her to call her mum on the phone and we had a very interesting chat. Turns out the she has seizures as a baby and child, usually when she had a temperature. She has continued to have attacks intermittently since but has never been diagnosed with epilepsy due to her normal tests.

2.What are the 3 important components of a blackout history?

Before, during and after.

Before – you get this from the patient. In this case, there is no warning. If there is a warning (funny smell, deja vu, focal twitching) then this suggests a structural lesion and the seizure, if it is one, will be FOCAL (perhaps going on to generalise)

During – her mum told me that she suddenly stares, then her eyes roll back and her neck goes stiff. She then extends her arms and falls to the floor with legs stiff and rigid. She makes a horrible noise and goes a bit blue in the lips. She jerks a little bit, usually after about 30 seconds have passed and then she stops.

After –  her mum told me that she is really drowsy afterward, complains of a headache, goes a vomits and then sleeps it off. She is not really back to normal for a few hours.

Conclusion - definite seizure

Top tip – get as  much detail as possible and really lead the witness. I know this is not supposed to be what you do, but people need help to describe the attack fully. Try this approach – “do you ever see the start of an attack? what happens in the first 5 seconds? then what? then what?” Don’t take “don’t know” for an answer.

3.Would you do any tests?

There is no need for fancy tests. The diagnosis is CLINICAL.

You must do an ECG. No excuses. Okay?

For adult-onset seizures, an MRI is mandatory these days. You are looking for a structural cause – tumour, cavernoma, mesial temporal sclerosis etc. CT is a bit of a waste of time.

There is no role for an EEG in the investigation of adult-onset seizures. Don't let anyone tell you otherwise. You can use them for juvenile-onset seizures that are only just presenting in adulthood, but please, please, please do not ask for an EEG to "rule in/out epilepsy" as a verbal slap in the chops from the neuro team often offends.

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