You have been asked to see a 52-year-old female in the Emergency Department who presented with a fever of 39.5ºC and generalised tonic-clonic seizures. Apart from a persistent reduced level of consciousness, her vital signs are currently stable.
a) List three central nervous system (CNS) and three non-CNS aetiological classifications for her presentation, with an example of each. (30% marks)
b) List six findings on physical examination that would be important in differentiating between potential diagnoses. (30% marks)
c) Describe the specific laboratory tests/investigations you would perform or request in this patient with justification for your inclusions. (40% marks)
This patient with seizures and a persistently decreased level of consciousness has status epilepticus by the standard definition (where you fail to recover your level of consciousness within a reasonable timeframe).
a) Three CNS "aetiological classifications" (or could we just call them "causes"):
Three extracranial reasons for fever and decreased level of consciousness:
b) Six findings on physical examination:
One could also include:
But- as one of the readers has pointed out - a typical examiner's response may be that "some candidates either listed investigations without a description, or included investigations that aren't sent to a laboratory, and scored zero marks."
Chapter 49 (pp. 549) Disorders of consciousness by Balasubramanian Venkatesh
Chapter 50 (pp. 560) Status epilepticus by Helen I Opdam
Tan, R. Y. L., A. Neligan, and S. D. Shorvon. "The uncommon causes of status epilepticus: a systematic review." Epilepsy research 91.2 (2010): 111-122.
Johnson, Nicholas, et al. "Anti-NMDA receptor encephalitis causing prolonged nonconvulsive status epilepticus." Neurology 75.16 (2010): 1480-1482.
Chen, James WY, and Claude G. Wasterlain. "Status epilepticus: pathophysiology and management in adults." The Lancet Neurology 5.3 (2006): 246-256.