Case Study

[medical22]

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A 50 year old female had a seizure event witnessed by her husband and was rushed to the ER. The event occurred after lunch when she became unconscious and fell to the floor. This was followed by jerking movements of the entire boy lasting for about 2 min. Upon arrival at the ER, she was drowsy but responsive. On further questioning, she remembered her right foot had shaken before the seizures. Other than that she claims that there were no other symptoms before the onset of the event.

Personal history: smoker since 25 years old. She is a middle school principal for the past 10 years.
Medical history: denies any recent illness or trauma.

PPE:
General survey: well nourished, quite responsive
Vital signs: bp= 140/70, PR=80/min; RR=17/min; Temp=100.5F
Heart and lungs: no murmurs, no rales
Nerological examination: normal gait, cranial nerves I-XII intact, sensory testing 5/5 bilaterally throughout the body, Positive Babinski, Kernig?s and Brudzinki?s negative

Questions:
What are the possible clinical entities? Discuss pros and cons (rule ins and rule outs) for each?
What type of seizure is being presented?
What other historical info will you ask?
Treatment?
Anything else you want to discuss?

Write the case in SOAP format.

I?ll put up the answer in a few days.

 

[Febrifuge]

Interesting. I'll have to subscribe to this thread and check back.

This is something for a class, right? Or is it a case you were witness to, in a work setting?

 

[doc05]

Originally posted by medical22
A 50 year old female had a seizure event witnessed by her husband and was rushed to the ER. The event occurred after lunch when she became unconscious and fell to the floor. This was followed by jerking movements of the entire boy lasting for about 2 min. Upon arrival at the ER, she was drowsy but responsive. On further questioning, she remembered her right foot had shaken before the seizures. Other than that she claims that there were no other symptoms before the onset of the event.

Personal history: smoker since 25 years old. She is a middle school principal for the past 10 years.
Medical history: denies any recent illness or trauma.

PPE:
General survey: well nourished, quite responsive
Vital signs: bp= 140/70, PR=80/min; RR=17/min; Temp=100.5F
Heart and lungs: no murmurs, no rales
Nerological examination: normal gait, cranial nerves I-XII intact, sensory testing 5/5 bilaterally throughout the body, Positive Babinski, Kernig?s and Brudzinki?s negative

Questions:
What are the possible clinical entities? Discuss pros and cons (rule ins and rule outs) for each?
What type of seizure is being presented?
What other historical info will you ask?
Treatment?
Anything else you want to discuss?

Write the case in SOAP format.

I?ll put up the answer in a few days.

this patient is suffering new onset seizure (generalized tonic-clonic) secondary to a brain tumor. Differential includes mets from lung; or a parasagittal meningioma.

SOAP format is used for progress notes. It is not indicated here.

 

[ckent]

1. Possible clinical diagnosis:
New generalized tonic-clonic seizure, syncope, cardiac arrhythia, brain stem ischemia, and pseudoseizure
Possible etiologies of generalized tonic-clonic seizures include traumatic, metabolic, neurologic, toxic, or infectious
2. simple partial seizure that evolving into generalized tonic-clonic seizure
3. Additional hx:
Would ask about any head trauma in the past
would ask about any meds/otc meds, EtOh and drug abuse hx
would ask about any bowel/bladder incontinence, any dysarthria, diplopia, dementia, hearing loss or any other neurological signs in the past
any sick contacts
ask about any fever, headache, lethargy, and confusion
any weight loss/gain, polyuria/polydypsia, back pain
would do a complete MSE
would do a complete ROS, ask about family hx of any seizure d/o, psych hx, HIV risk factors, surgical hx (spleen present)
ask about vaccination hx
4. Given elevated temp, menigeal signs, concern for meningitis, even though seizures are an unusual intial presentation of bacterial menigitis
would start Ceftriaxone and ampicillin
would get head ct, then LP. Measure opening pressure, send LP for cell count with diff, protein, glucose, cx.
would get EEG, MRI, CBC, chem 7, blood cx
additional hx may dictate additional tests...

Good case! Not sure why it's in the pre-med forum though

 

[medical22]

Febrifuge, no this is not for a class. I have a bunch of practice cases and I like to share them with the rest of you. I think it is fun to do and I personally learn a lot more from doing them together. I had started this in the summer and a lot of people like participating in it. I thought I'd continue it now again.

Ckent, which other forum would be better? I don't remember which one I used to post it in, maybe it was allopathic???

 

[ckent]

Yeah, allopathic, the general residency forum, or the internal medicine forum (my favorite) would be better. Give me the word and I can move this thread to any one of those for you.

 

[medical22]

sure you can move it to the Allopathic forum. I don't know how to do this. Thanks!

I was just reading up on meningitis and I think you would see a pos Kernig's and Brudzinki's. Am I correct? Besides the low-grade fever, how else can you support meningitis.

Why do you think the seizure is secondary to a brain tumor?

What about the symptom of the patient's right foot shaking before the seizure. What does this indicate?

 

[doc05]

actually, the right foot shaking was part of the seizure. technically, it began as a simple partial seizure, then progressed to generalized tonic-clonic.

based on her age and risk factors, I suspect brain tumor.

there is no reason to suspect meningitis.

a positive Babinski is not normal. on which side was it found?

 

[ckent]

Originally posted by doc05
actually, the right foot shaking was part of the seizure. technically, it began as a simple partial seizure, then progressed to generalized tonic-clonic.

based on her age and risk factors, I suspect brain tumor.

there is no reason to suspect meningitis.

a positive Babinski is not normal. on which side was it found?

Whoops, just re-reading the case and now I realize that the menigeal signs were negative. A low grade fever can be found in just about any intracranial process and is not suggestive of meningitis. Also, babinski sign is also fairly non-specific and can be found in many intracranial processes as well. Anyways, I retract my abx therapy and LP, and instead would just do everything else that I mentioned.

 

[Febrifuge]

Not that I have much to add, but just for fun, and to put a little spin on it, I would, er, question the husband since he saw it happen; determine whether C-spine stabilization is indicated (it doesn't seem to be), assess simple neuro (Philly Stroke Scale plus CMS and grip check, for example) at the scene after giving O2 at 15 lpm/ nonrebreather mask, and transport, getting vitals and hx on the way.

Depending on how fast my partner is driving, I might have a good portion of the Hx and PE for you guys when I arrive. (Since you have such good info and a clear picture to work with, I'm assuming it came with the help of some fine EMS in the field.) 🙂

...the above being appropriate to my level of training and scope of practice. Informally, I was going to say poss tumor or some sort of previous trauma. I'd lean more toward meningitis if she had neck pain, loss of ROM, or focal stiffness to boot.