Author: Tim Osborne / Editor: Sarah Edwards / Codes: CP4, NeuP3, RP8, SLO1, SLO2, SLO3 / Published: 10/11/2023
An 85-year-old woman presents to the Emergency Department (ED) with a one-day history of recurrent focal seizures.
Her general health was good until 4 months previously when she was admitted with atrial fibrillation and a rapid ventricular rate. An inpatient echocardiogram identified critical aortic stenosis with an ejection fraction of 30-35% for which she underwent a transcatheter aortic valve implantation (TAVI).
Her regular medications are: Apixaban 5mg BD, Bisoprolol 5mg OD and Furosemide 20mg OD.
She has had approximately 10-12 episodes lasting between 15 seconds and a minute. During these episodes there is a reduced level of consciousness, fixed gaze upwards and to the right and repetitive movements of the right upper limb. Usually there is a rapid recovery with no post-ictal period. There has been at least one episode of vomiting and some episodes of urinary incontinence.
On examination, there are bite marks to the lips. Cardiac examination reveals a systolic murmur, with no evidence of raised jugular venous pressure or peripheral oedema. Neurological examination does not reveal any significant abnormality.
Vital signs are as follows:
- Blood pressure 164/95
- Heart rate 61 irregular
- Respiratory rate 14
- Oxygen saturation 96%
- Temperature 36.5
A venous blood gas reveals a lactate of 4.8 mmol/L but is otherwise unremarkable.
Laboratory blood testing (full blood count, urea and electrolytes, liver function test, and C-reactive protein) is also unremarkable.
A non-contrast CT brain scan has been performed and reported as normal.
