Author: Annabel Doyle / Editor: Steve Fordham / Reviewer: Eugene Henry / Codes: A5, CC1, O7 / Published: 27/01/2021

A 47-year-old nurse with a 2 week history of headaches and lethargy presented with a pre-syncopal episode at work. She was pale and sweaty before the collapse and had slow speech during the episode. She remembered hearing voices but could not vocalise or follow commands. In the ED she had recovered somewhat but felt tired, with heavy limbs, a headache and felt like her “body did not belong to her”.

Her medical history included gallstones and depression and current medication was Hormone replacement therapy(HRT). She had stopped taking citalopram three weeks previously.

A further vague episode was witnessed in the department where she looked glazed, vacant and pale, but with no loss of consciousness or collapse.

Her blood pressure remained elevated at 200/111, HR 86, oxygen saturations 99% air and RR 22, temperature was 36.6 and GCS 15/15. Respiratory, cardiac and abdominal examinations were unremarkable. Her neurological examination revealed mildly decreased tone in all four limbs with normal power, sensation, reflexes and coordination. Her Abbreviated Mental Test Score (AMTS) was 10/10; however she was slow in answering questions and found it very difficult.

Initially a routine set of bloods, ECG, urine dip were performed.

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