Convulsion/fits/funny turns h istories

1. Convulsion/fits/funny turns histories Ben Ryan Final Year Medical Student

2. Remember, what are you trying to establish about the episode? • Are they still having a seizure now? Are they safe, airway patient, breathing? (A to E approach) • Is there a serious underlying cause, such as meningitis? • Could they have hurt themselves during the seizure? • What type of seizure was it? • Generalised? Focal? • Simple? Complex? • Tonic-Clonic? Absence? • Is this child usually well? • Establish a reasonable diagnosis

3. Some Differentials • Febrile convulsions • Fever, between 6 months and 5 years usually • Usually tonic-clonic, symmetrical, generalised seizure lasting less than 5 minutes • No signs of CNS infection, focal neurological signs or a previous history of epilepsy • Reflex Anoxic Seizure • Brief and spontaneous paroxysmal episodes trigger by fear, anxiety or pain • Episodes less than 1 minute • Typically becomes pale and limp, losing consciousness, followed by tonic-clonic movements • Tongue-biting is rare • Can have post-ictal grogginess

4. Differentials • Breath-holding attack • Often precipitated by emotion such as anger, frustration or trauma • A crying episode often ensues, breath is withheld and pallor/cyanosis develop • Loss of consciousness may occur, recovery usually quick • Meningitis • Unwell and drowsy child prior to convulsions with pyrexia • Non-blanching rash? Meningism?

5. Differentials • Epilepsy • Can cause many different types of seizures • May have a past history of similar episodes • Likely to be afebrile • Risk factors: birth asphyxia, cerebral palsy, trauma • May have symptoms before and after seizure • Others • Tuberous sclerosis • Vasovagal syncope (light-headed before hand, might have just stood up, can actually have some movements during • Benign paroxysmal positional vertigo – person moves rotates head and gets vertigo • Hypoglycaemic attack

6. With any episode or particular event, always think: • Were there any witnesses? Were you a witness? • Before • During • After

7. Structure to History • HPC • Witnesses • Before, During, After • ICE • Pregnancy and birth history • Development • Immunisations • Feeding History • Travel history if you’re feeling peppy • Everything else

8. HPC • Witness? Open question • Where did it occur, when did it occur, how long did it last? • Before • Any triggers? What were they doing before hand? • Video games/TV/scared/crying • Trauma • General Health? • Fever? Skin changes (non-blanching rash?) Complaints of neck stiffness of pain? • Aura – any funny feelings before hand • Previous Episodes?

9. HPC • During • Open question • How long did it last? • Did it stop and then start again? (emergency?) • Lose consciousness? • Any falls or trauma? • Was he shaking? Can you describe it for me? Whole body shaking? • Did he go stiff? Everywhere? • Tongue-biting? On the front, or on the side? (biting side of tongue is a good indicator of tonic-clonic seizure) • Incontinence? • Pallor/cyanosis?

10. HPC • After • Open Question • How did they feel afterwards? • Any memory of it? • General health now?

11. ICE • Make a big thing of telling the parent that it isn’t their fault as soon as they can

12. Pregnancy and Birth History • Prenatal • Open question • Any illnesses? Smoking/alcohol/drugs? Any complications during pregnancy or labour? • Peri-natal? • Normal delivery? Assisted? C-section? • When in pregnancy was he born? Birthweight? • Post-natal? • Well after delivery? • Require admission?

13. Development History • Any developmental concerns? • Can do a quick screen of the 4 categories if you like, if it feels appropriate • Gross motor • Fine motor and vision • Hearing, speech and language • Social and behavioural

14. Immunisations and Feeding History • Immunisations • Always important, especially as meningitis is among your differentials and many of the vaccinations are against bacterial causes of meningitis • Just ask if their up to date with their vaccinations • Feeding • Are they eating well, drinking well? Passing urine and faeces okay?

15. PMH, DH, FH • Any other medical problems? • On any medications? • Any allergies? • Any conditions run in the family? • Can ask about epilepsy and febrile convulsions • Who is at home? Any problems? • School, playgroup, nursey? Any problems?

16. Important Points • Clarify who the adult is and their relationship with child • Pregnancy and birth history is important – exposure to toxins and risk factors • Parent likely to be very distressed • Reassure as soon as you get the opportunity – get the SP on your side • Likely concern from parent is that their child has epilepsy

17. Then what? • Many 4th year OSCE history stations have a combination of history + explanation • I typically put 6 minutes into the history, 2 into the explanation • Clearly explain the diagnosis, emphasising key words (pausing etc.) • Explain that it’s nobody’s fault (it probably isn’t) • Explain what is going to happen immediately (admission? Investigations?) • Explain what can be done long-term (advice, safety netting, teach parent’s recovery position, patient information leaflets) • Explain future complications/risk of recurrence • Answer any questions and concerns