A 72-year-old man comes to the surgery with his wife

A 72-year-old man comes to the surgery with his wife.
She has witnessed two seizures at home, both of which have lasted for no longer than two minutes or so,
accompanied by generalised limb jerking and incontinence of urine. He has been very embarrassed about the
problem and did not want to come for review. She did not call an ambulance at the time as he seemed to be
comfortable afterwards and she did not want the staff to see him “in a mess”.
He has a history of cerebrovascular disease having suffered a minor stroke one year earlier, and suffered a
myocardial infarction some three years ago. Medication includes ramipril, amlodipine, atorvastatin and aspirin.
On examination in the surgery he looks well. His BP is 142/79 mmHg, his pulse 75 and regular. Neurological
examination is unremarkable apart from some very minor loss of co-ordination affecting his left hand. He wants
you to arrange some investigations before bothering the hospital doctors.
Investigations show
Haemoglobin 12.1 g/dl (13.5-18)
White cell count 8.2 x 109/l (4-10)
Platelets 301 x 109/l (150-400)
Sodium 141 mmol/l (134-143)
Potassium 5.1 mmol/l (3.5-5)
Creatinine 149 μ/l (60-120)
ESR 12 (<20)
ECG Sinus rhythm
Inferior Q waves
Which one of the following initial steps would be most appropriate in this case?

Carotid ultrasound scanning (Correct)
EEG
Start low dose carbamazepine
Start low dose sodium valproate
Tilt table test

EEG measurement is less useful in an elderly population, most likely because of structural changes related to
age and pre-existing cerebrovascular disease. MRI however may be useful in detecting any structural
abnormality such as a tumour, local vascular abnormality or old cerebral infarct.
In patients with a history of previous stroke foci of epileptic activity can occur in the penumbra around the
previous infarct. In view of his previous stroke, carotid ultrasound scanning is also an important part of the
initial assessment.
Finally, bearing in mind his previous infarct, he should be considered for 72 hour ECG monitoring, to exclude
the possibility of a significant cardiac arrhythmia.