Patient with seizures

57 y/O female presents to ED with numerous seizures over preceding days.

Patient reports seizures started following traumatic head injury 5 years ago(MVA) . Nothing before this time. Seen by neurology as an outpatient and initiated on sodium valproate with minimal effect. dose pushed untill side effects and trailed dual therapy with carbamazepine.

Gets some warning, husband describes her knocking on the window when hes outside. When he comes in, on floor unconscious. Regains consciousness after few seconds. usually a bit groggy when she comes around.

Her exam was unremarkable.

ECG (sorry I didnt scan) Was sinus brady 50 BPM.

Patient was admitted to the ward for observation and treatment of prolonged seizures.

Whilst on the ward patient reported feeling one coming on. See trace below.

So I arrived to her looking a horrible shade of pale with the alarms ringing. Her husband was arguing with the nurse as she was trying to put pads on her. “shes fine give it 30 seconds she will be ok” “This happens all the time”

By the time I got to the bedside patient she was responsive and said to me “I guess I had another one?”

Discussion was had around when is ventricular standstill, asystole?

Here is the patients strip post treatment. Follow-up at 3 months, seizure free.

Things come in Twos

So ive been covering medical wards this week

Had a call on monday about a lovely syncopal lady who untill the last week was still doing, Scottish highland dancing, Aquarobics, and Spin classes. Apparently she had an AS murmur but such good function so had never been investigated.

So she came to me with an episode of syncope. Walking up a slight incline, stopped twice as lightheaded and the final time after attempting to continue collapsed. Firstly i sorted out her face, stiched her up and had a good look at her.

She really was an awesome 85 Y/O lady. I was really not that convinced she had a slow rising pulse but she had an awesome ESM murmur Grade 5.5. (when you believe you can hear it from the end of the bed!)

Plan was to keep her for the night as was 10pm and get USS ect organised for the morning. 

I went down for the USS and had a play (attached photo is not mine) i wish i could get the perfect view but as just learning its not that pretty.

 

I thought this was pretty impressive, peak of >100mmHg and mean >60mmHg.

Discussed with cardiology and shes off to our teritary centre for work up to a percutaneous valve replacement.

Then yesterday afternoon got a call about a nice bloke with CHF and fast AF, ESM murmur.

Arrives to me pretty wet. had 80 IV frusemide and responded well. Bumped up his digoxin which was subtheraputic week before and his rate settled nicely.

Whilst having a look at him and his old records hes on the waitlist for a TAVI…due to happen in feb 2012. AS with peak 95mmHg and mean >60…

Cool CT recon from his work up

 

So that was my Duo of tight AS with clear symptoms. Also first time I have seen Exhertional syncope secondary to AS.

So questions for anyone/everyone. What have you had come in twos or threes?