Collapse / Syncope OSCE - Seizure

Diagnosis: Seizure

Case Overview

  • Age/Sex: 21-year-old male
  • Occupation: University student, semi-professional athlete (soccer)
  • Setting: Emergency department after collapse on campus during training
  • Chief complaint: "I collapsed and blacked out"

Patient Script

Who I Am

I'm a 21-year-old university student who plays for the college soccer team and trains most days.

What Brings Me In

I was told I collapsed and had shaking all over — I don't remember most of it and woke up confused.

My Story

I was training with my team yesterday evening at about 7:00 pm when I suddenly fell to the ground. The next thing I remember is later on the grass feeling tired and sore. My teammates said I had rhythmic jerking of my arms and legs for about a minute to a minute and a half, and they saw me bite my tongue and pass urine. I was unresponsive during that time and then slowly came round over the next 10–20 minutes but felt confused and sleepy for about 30 minutes. I have a sore, bitten tongue now and a dull headache.

I don't remember any warning before I fell — I think I might have felt a bit tired earlier in the day, but no clear lightheadedness or chest pain right before. I usually feel fine during training, but I have been trying a new pre-workout supplement this week and had an energy drink about an hour before practice (it was a powder shake). I also trained hard in the heat earlier that day and drank a lot of water.

My Medical Background

  • Past medical history: none, never been told I have epilepsy
  • Medications: multivitamin, protein powder, the new pre-workout supplement (contains caffeine) — started this week
  • Allergies: none
  • Social: non-smoker, drinks socially (last had alcohol 3 days ago), denies recreational drugs but admits energy drinks and supplements; lives with teammates
  • Family: a cousin once had "seizures" as a child (not sure of details)

What I Think & Worry About

  • I think I might have had a seizure and I'm worried this means I have epilepsy.
  • I'm scared I might be banned from playing sports or driving.
  • I'm worried there might be something wrong with my heart.

If You Ask Me About Other Symptoms...

  • "Did you feel dizzy beforehand?" — I might have felt a bit tired, but I didn't have a clear dizzy spell where everything went lightheaded before I fell.
  • "Any chest pain or palpitations?" — I felt my heart racing sometimes when I try the pre-workout, but nothing right before I collapsed.
  • "Any headache or weakness now?" — I have a mild headache and my legs feel achey, but I can move them; no ongoing weakness on one side.
  • "Any previous episodes?" — I fainted once when I was a kid after getting a shot, but that was ages ago and different.
  • "Recent drug or alcohol use?" — I had a beer three days ago; I don’t use recreational drugs.
  • "Any recent illness or fever?" — No fevers or infections lately.
  • "Any features during the event?" — I'm told I was stiff then had jerking, and I bit my tongue on the side. I wet myself a bit.

Clinical Summary

Examination

  • General: alert now but mildly drowsy and a bit slow to answer initially
  • Vitals: Temperature 37.2°C; HR 96 bpm; BP 118/76 mmHg; RR 16/min; SpO2 98% on air
  • Cardiorespiratory: chest clear, heart sounds normal, no murmurs
  • Neurological: GCS 15 now; pupils equal and reactive; cranial nerves intact; no focal motor or sensory deficit; gait not formally tested (muscle soreness); speech slightly slurred initially
  • Other: small lateral tongue bite on the left with superficial abrasion; mild urinary incontinence reported by teammates; no signs of head injury

Investigations

  • Capillary glucose: 5.8 mmol/L (normal) — hypoglycaemia unlikely
  • Serum electrolytes: Na 139 mmol/L, K 4.0 mmol/L, Cl 102 mmol/L, HCO3 24 mmol/L (within reference)
  • Serum calcium: 2.30 mmol/L (normal)
  • CK: 420 U/L (mildly elevated, consistent with recent convulsive activity)
  • Full blood count: WCC 8.5 x10^9/L, Hb 145 g/L, platelets 250 x10^9/L (normal)
  • ECG: sinus rhythm 92 bpm, no ischaemic changes or conduction block
  • Serum ethanol: undetectable
  • Urine drug screen: pending / not reliably sensitive for supplements
  • CT head (non-contrast): no acute intracranial haemorrhage or mass
  • EEG: arranged as outpatient / inpatient depending on local protocol (may show epileptiform activity but often normal after a first seizure)

Diagnosis

  • Primary diagnosis: Generalised tonic-clonic seizure (first unprovoked seizure)

    • Supporting evidence: witnessed sudden collapse with tonic then clonic jerking lasting ~60–90 seconds, lateral tongue bite, urinary incontinence, and postictal confusion/somnolence lasting ~20–30 minutes; normal glucose and electrolytes; mild postictal CK rise; normal ECG and CT head.

  • Differential diagnoses:

    • Vasovagal syncope: less likely given prolonged convulsive movements, tongue injury, and prolonged post-event confusion.
    • Cardiac arrhythmia leading to syncope: less likely given normal ECG and presence of typical seizure features; consider ambulatory ECG if suspicion persists.
    • Psychogenic non-epileptic attack (PNES): less likely with observed tonic-clonic activity, tongue bite, urinary incontinence, and postictal confusion, but consider if atypical features or inconsistent witness reports.
    • Hypoglycaemia / metabolic disturbance: excluded by normal glucose and electrolytes.

Management

  • Immediate:

    • Ensure airway, breathing, circulation; monitor observations and oxygen if required.
    • No benzodiazepine needed now (patient is not seizing); be prepared to treat with IV lorazepam if a seizure reoccurs or is prolonged (>5 min).
    • Analgesia and wound care for tongue laceration.

  • Investigations and referrals:

    • Arrange urgent neurology review / referral for first seizure.
    • Arrange an urgent or semi-urgent EEG (timing per local protocol).
    • Arrange MRI brain as outpatient to look for structural causes (preferred over CT for non-emergent imaging after first seizure).
    • Consider 24–48 hour Holter/ambulatory ECG if any history suggestive of arrhythmia.

  • Longer-term and counselling:

    • Do not drive or operate heavy machinery until cleared according to local driving regulations (advise immediate driving cessation and follow-up with licensing authority).
    • Advise avoidance of alcohol bingeing and caution with stimulants/pre-workout supplements until reviewed by neurology.
    • Discuss temporary restriction from competitive contact sport until neurology review and risk assessment completed.
    • Do not start antiepileptic medication empirically after a single unprovoked seizure unless high risk factors (e.g., prolonged focal deficits, abnormal imaging, recurrent seizures) — decision to be made by neurology.

Key Learning Points

  • Witnessed tonic-clonic movements with lateral tongue bite, urinary incontinence, and a prolonged postictal state strongly suggest a generalised tonic-clonic seizure rather than vasovagal syncope.

  • Initial evaluation of a first seizure includes immediate ABCs, point-of-care glucose, electrolytes, ECG, neuroimaging when indicated (CT emergently if concerning features), CK may be raised postictally, and prompt neurology referral for EEG and MRI.

  • Do not rush to start antiepileptic drugs after a single unprovoked seizure without neurology input; ensure safety counselling (driving, sports, substances) and arrange timely outpatient investigations.

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