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A 60-year-old woman is admitted to the hospital after a loss of consciousness. She had a “strange feeling” before losing consciousness. Her husband stated that she fell to the ground and had generalized stiffening and then shaking. She was unresponsive for approximately 1 minute, had urinary incontinence, and was confused for a few minutes after regaining consciousness. She had a similar episode 2 months ago; evaluation at that time, which included electrocardiography, stress electrocardiography, and a continuous-loop event electrocardiographic recorder, revealed no abnormal findings. The patient takes no medications.

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Physical examination including a full neurologic examination is normal.

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MRI of the brain and electroencephalogram (EEG) during waking and sleeping are also normal.

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1. What is the most likely diagnosis?

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Answer

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  1. The patient likely had a seizure. Seizure is classified according to the history and physical examination. Diagnostic testing is used to confirm or clarify the suspected cause. When a patient has loss of consciousness with urinary incontinence and stiffening and shaking lasting 1 to 2 minutes, seizure should always be considered as the cause until proven otherwise. When there is a high clinical suspicion of epilepsy, normal MRI of the brain and EEG do not rule out that diagnosis.

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Seizures

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The first step in evaluating a patient with a suspected seizure is to rule out other conditions, such as syncope or a transient ischemic attack. As is most often the case, a complete history and physical examination are essential. Based on the results of those examinations, one pursues appropriate diagnostic testing. If a seizure is suspected, the next step is to distinguish between provoked (secondary) and unprovoked (primary) seizure. Acute symptomatic seizures are usually secondary to an acute neurologic event or to a metabolic problem.

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Appropriate management should be aimed at correcting the underlying cause. Antiseizure medication is reserved for refractory seizures or primary seizures (epilepsy) only. Epilepsy is a condition of at least 2 or more unprovoked seizures. It is appropriate to get a neurology consult when the diagnosis is unclear or when medication choice is difficult. Otherwise neurology consultation is often unnecessary.

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In the majority of patients with epilepsy, no reversible cause of the seizures is found. Elderly patients more commonly have an identified etiology. Cerebrovascular disease is responsible for approximately 30% of seizures in older patients.

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Diagnosis

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Seizures are classified into 2 types: generalized and partial. Generalized seizures affect both sides of the brain and are not usually associated with a cerebral lesion. Partial seizures arise from a localized area and may indicate the possibility of an underlying lesion.

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Seizures may be accompanied by loss of consciousness. Three seizure types include a loss of consciousness: complex partial seizures, absence seizures, and generalized tonic-clonic seizures. Since patients have lost consciousness ...

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