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Answers on p 213.
A 67 year old woman was admitted to hospital because of intractable seizures. She was brought to our emergency department by her husband; he was frequently hospitalised in our institution. She had no previous history of epilepsy, alcoholism, or other neurological problems. She took benzodiazepines regularly for anxiety and sleep disorders. Examination showed a typical convulsive generalised tonic-clonic seizure, followed by myoclonic jerk of the right arm.
Her temperature was 36°C, the pulse was irregular at 140 beats/min, and blood pressure was 130/70 mm Hg. The biochemical tests showed potassium at 2.4 mmol/l, phosphate 0.35 mmol/l, calcium 2.5 mmol/l, sodium 139 mmol/l, creatinine 60 mmol/l, aspartate transaminase 47 UI/l, and alanine aminotransferase 25 UI/l.
Electrocardiography showed atrial fibrillation. An electroencephalogram disclosed left anterior epileptiform activities. Computed tomography of the brain demonstrated cortical atrophy only. Despite intravenous diazepam and valproic acid, she required intubation and assisted ventilation for status epilepticus.
- What is the missing biochemical request?
- What is the most probable diagnosis?
- What further investigation would you perform?