CASE 61: LOSS OF CONSCIOUSNESS
History
A 52-year-old man is brought to the emergency department by ambulance. His wife gives
a history that, while standing at a bus stop, he fell to the ground and she was unable to
rouse him. His breathing seemed to stop for about 20 s. He then developed jerking move-
ments affecting his arms and legs lasting for about 2 min. She noticed that his face became
blue and that he was incontinent of urine. He started to recover consciousness after a few
minutes although he remains drowsy with a headache. The man has not complained of any
symptoms prior to this episode. There is no significant past medical history. He is a taxi
driver. He smokes 20 cigarettes per day and consumes about three pints of beer each night.
Examination
He looks a fit and well-nourished man. He is afebrile. There is some bleeding from his
tongue. His pulse is 84/min and regular. His blood pressure is 136/84 mmHg. Examination
of his heart, chest and abdomen is normal. There is no neck stiffness and there are no focal
neurological signs. Funduscopy is normal. His Mini-mental test score is normal.
NormalHaemoglobin 15.6 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 85 fL 80–99 fL
White cell count 5.2% 109 /L 3.9–10.6% 109 /L
Platelets 243 % 109 /L 150–440% 109 /L
Sodium 138 mmol/L 135–145 mmol/L
Potassium 4.8 mmol/L 3.5–5.0 mmol/L
Urea 6.2 mmol/L 2.5–6.7 mmol/L
Creatinine 76 &mol/L 70–120&mol/L
Glucose 4.5 mmol/L 4.0–6.0 mmol/L
Calcium 2.25 mmol/L 2.12–2.65 mmol/L
Phosphate 1.2 mmol/L 0.8–1.45 mmol/LINVESTIGATIONS
Questions
- What are the differential diagnoses of this episode?
- How would you investigate and manage this patient?
- What implications does the diagnosis have for this man’s livelihood?