Who you are:
You are a FY2 in A&E.Who the patient is:
Marcus Jones, 26 years old, booked an urgent appointment with you because he thinks he had fit at home.What you should do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of management with the patient.
- Don’t forget DRIVING
- Ask about HOBBIES
- Differentials:
– Trauma
– Meningitis
– Encephalitis
– Stroke
– Syncope
– Brain tumour
Seizure triggers
For many people with epilepsy, seizures seem to happen randomly. But sometimes they can have a trigger, such as:
- Stress
- A lack of sleep
- Waking up drinking alcohol
- Some medicines and illegal drugs
P1(ODIPARA)
Doctor: I can see from my notes that you booked an urgent appointment, is everything ok?
Patient: I think I had a fit doctor.
D: I see, can you please tell me more about it?
P: Yesterday, I was watching tv with my wife when suddenly I lost consciousness, and I wasn’t responding to her for 2 mins (+ve finding)
D: That must have been a scary experience for you and your wife.
BEFORE – DURING - AFTER
D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did you feel like the room is spinning? (Meniere’s)
P: No.
D: Any trauma to your head?
P: No.
D: Any visual or auditory symptoms?
D: No.
D: Any fever/flu-like symptoms? (Confusion)
P: No.
D: Do you remember what happened during your fit or did your wife tell you about what you were doing? (Epilepsy)
P: Yes, she told me I was shaking and making weird movements. (+ve finding) D: I am going to ask you some questions that might be worrying but they are an important part of my consultation. By any chance did you bite your tongue?
P: No.
D: Wet yourself?
P: Yes, I soiled myself doctor. (+ve finding)
D: Did you remember anything after the fits?
P: No.
D: Did you feel any headache after that?
P: Yes, I had a headache, and I was confused also. (+ve finding)
D: Did you notice any weakness in your body?
P: No.
FLAWS
P2 (PAST HX)
D: Have you ever had this problem before?
P: No.
D: Do you have any medical condition?
P: No.
DESA
D: Tell me about your diet?
P: I try to eat healthy
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you use any recreational drugs?
P: No.
D: Do you do physical exercise?
P: No.
D: Do you have any kind of stress?
P: No.
MAFTOSA
D: Are you taking any medications?
P: No.
D: Any family history of fits?
P: No.
D: What do you do for living?
p: I am a taxi driver.
D: Whom do you live with?
P: I live with my wife.
D: Any activity or hobbies you like to spend your free time doing?
P: No
ICE
Examination:
→ Observations
→ Head to toe include Neurological: (examine heart).
Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you had a shaking fit and you soiled yourself after it. You couldn’t remember what happened and you felt confused. So, I believe what you experienced was a seizure attack, there are a lot of causes that can cause this but the most common one is called Epilepsy.
Management:
- SENIOR.
- Urgent referral to specialist
- He will examine and reassess you and carry out more investigations like:
– EEG: examine electrical activity of the brain
– CT scan
– Start you on medications if epilepsy is confirmed.
- General advice
Keeping a diary of when you have seizures and what happened before them can help you identify and avoid some possible triggers.
Some people with epilepsy wear a special bracelet or carry a card to let medical professionals and anyone witnessing a seizure know they have epilepsy.
Identify and avoid seizure triggers
Driving: You must stop driving and tell the Driving and Vehicle License Agency (DVLA) if you’ve had a seizure. If you don’t you could end up in a serious fatal accident.
- Sports and leisure: avoid swimming or doing water sports on your own, wear a helmet while cycling or horse riding, avoid using certain types of gym equipment; ask staff at the gym for advice.
- Support groups:
There are 2 main epilepsy support groups that you might find a useful source of information and advice.
- Epilepsy Action - Epilepsy Society
- What to do during the attack
If someone is with you while you’re having a seizure: they should only move you if you’re in danger, such as near a busy road or hot cooker.
They should cushion your head if it’s on the ground, loosen any tight clothing around your neck, such as a collar or tie, to aid breathing and turn you on to your side after the convulsions stop.
Your family should read more about the recovery position and learn how to put you in it. They should stay with you and talk to you calmly until you recover. They should also note the time the seizure starts and finishes.