IM Board Review

A 50-year-old woman with new-onset seizure

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Release date: January 1, 2018
Expiration date: December 31, 2018
Estimated time of completion: 1 hour

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A 50-year-old woman presented to the emergency department after a witnessed loss of consciousness and seizurelike activity. She reported that she had been sitting outside her home, drinking coffee in the morning, but became very lightheaded when she went back into her house. At that time she felt could not focus and had a sense of impending doom. She sat down in a chair and her symptoms worsened.

According to her family, her eyes rolled back and she became rigid. The family helped her to the floor. Her body then made jerking movements that lasted for about 1 minute. She regained consciousness but was very confused for about 10 minutes until emergency medical services personnel arrived. She had no recollection of passing out. She said nothing like this had ever happened to her before.

On arrival in the emergency department, she complained of generalized headache and muscle soreness. She said the headache had been present for 1 week and was constant and dull. There were no aggravating or alleviating factors associated with the headache, and she denied fever, chills, nausea, numbness, tingling, incontinence, tongue biting, tremor, poor balance, ringing in ears, speech difficulty, or weakness.

Medical history: Multiple problems, medications

The patient’s medical history included depression, hypertension, anxiety, osteoarthritis, and asthma. She was allergic to penicillin. She had undergone carpal tunnel surgery on her right hand 5 years previously. She was perimenopausal with no children.

She denied using illicit drugs. She said she had smoked a half pack of cigarettes per day for more than 10 years and was a current smoker but was actively trying to quit. She said she occasionally used alcohol but had not consumed any alcohol in the last 2 weeks.

She had no history of central nervous system infection. She did report an episode of head trauma in grade school when a portable basketball hoop fell, striking her on the top of the head and causing her to briefly lose consciousness, but she did not seek medical attention.

She had no family history of seizure or neurologic disease.

Her current medications included atenolol, naproxen, gabapentin, venlafaxine, zolpidem, lorazepam, bupropion, and meloxicam. The bupropion and lorazepam had been prescribed recently for her anxiety. She reported that she had been given only 10 tablets of lorazepam and had taken the last tablet 48 hours previously. She had been taking the bupropion for 7 days. She reported an increase in stress lately and had been taking zolpidem due to an altered sleep pattern.

PHYSICAL EXAMINATION, INITIAL TESTS

On examination, the patient did not appear to be in acute distress. Her blood pressure was 107/22 mm Hg, pulse 100 beats per minute, respiratory rate 16 breaths per minute, temperature 37.1°C (98.8°F), and oxygen saturation 98% on room air.

Examination of her head, eyes, mouth, and neck were unremarkable. Cardiovascular, pulmonary, and abdominal examinations were normal. She had no neurologic deficits and was fully alert and oriented. She had no visible injuries.

Blood and urine samples were obtained about 15 minutes after her arrival to the emergency department. Results showed:

  • Glucose 73 mg/dL (reference range 74–99)
  • Sodium 142 mmol/L (136–144)
  • Blood urea nitrogen 12 mg/dL (7–21)
  • Creatinine 0.95 mg/dL (0.58–0.96)
  • Chloride 97 mmol/L (97–105)
  • Carbon dioxide (bicarbonate) 16 mmol/L (22–30)
  • Prolactin 50.9 ng/mL (4.5–26.8)
  • Anion gap 29 mmol/L (9–18)
  • Ethanol undetectable
  • White blood cell count 11.03 × 109/L (3.70–11.00)
  • Creatine kinase 89 U/L (30–220)
  • Urinalysis normal, specific gravity 1.010 (1.005–1.030), no detectable ketones, and no crystals seen on microscopic evaluation.

Electrocardiography showed normal sinus rhythm with no ectopy and no ST-segment changes. Chest radiography was negative for any acute process.

The patient was transferred to the 23-hour observation unit in stable condition for further evaluation, monitoring, and management.

SIGNS AND SYMPTOMS OF SEIZURE

1. What findings are consistent with seizure?

  • Jerking movements
  • Confusion following the event
  • Tongue-biting
  • Focal motor weakness
  • Urinary incontinence
  • Aura before the event

All of the above findings are consistent with seizure.

The first consideration in evaluating a patient who presents with a possible seizure is whether the patient’s recollections of the event—and those of the witnesses—are consistent with the symptoms of seizure. 1

In generalized tonic-clonic or grand mal seizure, the patient may experience an aura or subjective sensations before the onset. These vary greatly among patients. 2 There may be an initial vocalization at the onset of the seizure, such as crying out or unintelligible speech. The patient’s eyes may roll back in the head. This is followed by loss of muscle tone, and if the patient is standing, he or she may fall to the ground. The patient becomes unresponsive and may go into respiratory arrest. There is tonic stiffening of the limbs and body, followed by clonic movements typically lasting 1 to 2 minutes, or sometimes longer. 1,3,4 The patient will then relax and experience a period of unconsciousness or confusion (postictal state).

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