Pause for Thought

Author: Tim Osborne / Editor: Sarah Edwards / Codes: / 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.

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