4 Case 1Donna, a 24 year old secretary is brought to surgery by her mother. Her mother thinks she may have had a fit the day before. She says that she was watching TV and suddenly started shaking for 1 -2 minutes. This has never happened before and she is normally well.What aspects do you need to know in the history?What investigations should you arrange?What is your diagnosis and management plan and how do you explain this to Donna?
6 Differentiating seizure from syncope: helpful and unhelpful features Unhelpful features—often mistakenly thought to indicate seizure but can occur in syncopeTwitching and jerkingIncontinence (reflects a full bladder at the time of the event)PallorBitten tip of tongueFatigue after the eventHelpful features—indicate a seizureConfusion after the event lasting >2 minutesDeeply bitten lateral border of the tongueTonic then clonic movement lasting >1 minuteDeep cyanosis
7 Reported risk factors for seizure recurrence Remote symptomatic aetiology (pre-existing static brain abnormalities that are, by implication, causative)Focal neurological findingsFocal seizure phenomenology (including Todd's paresis)Focal or generalised epileptiform activity on EEGTumours or other progressive lesions as the underlying pathologyStatus epilepticusFamily history of epilepsyPrevious febrile seizures
9 Mr. Palmer is a 56 year old pharmacist who complains of tiredness and pain in his right shoulder. Work is becoming difficult. His wife has said he is slow doing everything.He has a past history of vertigo and hypertensionMedication-lisinopril 5mg dailyWhat else do you want to know from the history?How would you examine this man?What is your management plan and explanation?
10 Resources Parkinson’s Treatment Centre, Gorseinon NICE:CG35 Parkinson's disease full guideline.mhtPatient and doctor information: Parkinson's Disease Society - Resources for GPs.mht
11 Sarah, a 25 year old teacher, complains of headaches Sarah, a 25 year old teacher, complains of headaches. She describes a pain on the right side of her head, mostly around the eye. The pain is severe and makes her feel sick or vomit. She has had three of these headaches in the last 6 weeks. She is worried she may have a brain tumour.What important factors do you need to elicit from the history?What examination would you perform?What is your management plan?
12 Resources Bandolier: IHS criteria for migraine British Association for the Study of Headache: Diagnosis and Management of Headache