“He said I was shaking… but I don’t remember a thing.”
— A step-by-step approach to seizure-like episodes in primary care.
How do you approach a patient who reports an episode of “shaking and loss of consciousness”? These mock scenarios will help you practice history taking, differential diagnosis, and communication skills in real-world seizure presentations. Ideal for OSCE, USMLE Step 2 CS, and OET Speaking practice.
🩺 Case 1 – Standard Case
“I don’t remember anything after I fell”
🔶 Doorway Information
- Age/Gender: 27-year-old male
- Chief Complaint: “I collapsed and had convulsions yesterday, according to my friend.”
- Vital Signs: T 36.8°C, HR 84 bpm, BP 122/76 mmHg, RR 16, SpO₂ 98% (room air)
🔶 Shoreline
The patient came to the clinic one day after collapsing during dinner with a friend. He reportedly lost consciousness and had full-body shaking for a few minutes. He remembers feeling normal before the incident and waking up on the floor with a sore tongue.
🗂 Structured History
🔹 Opening
“My friend said I suddenly collapsed and started shaking. I really don’t remember what happened.”
🔹 Onset & Course
“It happened yesterday evening, maybe around 7 PM. One moment I was sitting, the next thing I remember is waking up on the floor.”
“It was all of a sudden, no warning signs. My friend told me I was shaking all over for about 2–3 minutes.”
🔹 Associated Symptoms
“My tongue hurts and I think I bit it. I also had some urine in my pants when I woke up. I felt really tired and confused afterward.”
“No chest pain, no palpitations, no shortness of breath. No headache or limb weakness.”
🔹 Mood / Function / Appetite / Sleep
“I’ve been a bit stressed with work, but nothing out of the ordinary. I eat and sleep normally.”
🔹 Medical History / Medication
“I’ve never had anything like this before. No medical problems. I’m not taking any medications.”
🔹 Family & Social History (PAM HITS FOSS)
- Previous & Past medical history: Unremarkable
- Allergy: None
- Medication: None
- Hospitalization: None
- Injury / Trauma / Surgery: None
- Family history: “My uncle had epilepsy, I think.”
- OBGYN: N/A
- Sexual history: “I have a girlfriend. No STIs or anything.”
- Social history: “I drink on weekends, socially. No drugs. I’m an engineer.”
🔹 Concerns & Questions
“Is this epilepsy? Will this happen again? Do I need to stop working or driving?”
🔬 Physical Examination
- General: Alert, oriented, no distress
- HEENT: Lateral tongue bite noted; no head trauma or nystagmus
- Cardiopulmonary: Heart sounds normal, clear lungs
- Neuro: CN II–XII intact, normal strength and reflexes, no focal deficits, negative Romberg
- Skin: No bruises or signs of incontinence at present
🧠 Differential Diagnosis
Most likely diagnosis: First-time generalized tonic-clonic seizure
- Supporting: Sudden LOC, bilateral tonic-clonic movements, postictal confusion, tongue bite, incontinence
- Against: None strongly; single episode, no prior history
2nd: Vasovagal syncope with convulsive features
- Supporting: Possible trigger, young male
- Against: No prodrome, classic postictal signs present
3rd: Psychogenic non-epileptic seizure (PNES)
- Supporting: Work stress, no prior epilepsy
- Against: Physical signs (tongue bite, incontinence) not typical of PNES
🧭 Clinical Reflection
This likely represents a first unprovoked generalized seizure. EEG and MRI are needed to rule out structural or epileptogenic causes. Patient education and safety counseling, especially around driving and recurrence risk, are key parts of early management.
💡 Clinical Pearls
- 🧠 First-time seizure ≠ epilepsy — diagnosis requires recurrence or evidence of epileptogenic tendency.
- 🛌 Postictal confusion, tongue biting, and incontinence help distinguish seizures from syncope or PNES.
- 🧪 Always check glucose, electrolytes, and toxicology in new-onset seizure.
- 🚗 Driving restrictions vary by country—know the local regulations.
- 🧲 Brain MRI is more sensitive than CT in identifying structural causes of seizures.
❓ Challenging Questions
Q: “Is this definitely epilepsy?”
A: “That’s one possibility, but we need more information. There are several other conditions that can cause this. We’ll do the right tests to rule things out. You’re not alone—we’ll go through this step by step.”
Q: “Can I go back to work or drive?”
A: “That’s an important question. Many places require a seizure-free period before driving again. For work, it depends on what you do and how stable things are—we’ll talk about it after your tests.”
Q: “Will I need medications right away?”
A: “We usually wait to see if seizures recur before starting medication, unless there’s something on your imaging or EEG. We’ll decide together after gathering more information.”
📝 SOAP Note
S: 27-year-old male presents after a witnessed convulsive episode last night. Friend reported sudden loss of consciousness, generalized shaking lasting ~2–3 min, followed by confusion. Patient has tongue bite and possible incontinence. No similar episodes before. O: - Vitals stable: T 36.8°C, HR 84, BP 122/76, RR 16, SpO₂ 98% - Alert and oriented - Lateral tongue bite present - Neuro exam: CNs intact, normal strength and reflexes, no focal deficits - No trauma signs A: # First-time seizure episode # Postictal confusion, tongue bite, incontinence # No clear provocation, unremarkable history ddx): - Generalized tonic-clonic seizure - Vasovagal syncope with convulsion - PNES, hypoglycemia, alcohol withdrawal r/o): - Syncope (no prodrome, postictal signs suggest seizure) - PNES (physical signs favor true seizure) - Structural brain lesion or metabolic causes pending evaluation → Likely first unprovoked seizure. Needs EEG, MRI, and labs to evaluate etiology. Patient advised on safety and driving. P: - Order labs (CBC, CMP, glucose, Na, Ca, Mg, Cr) - Brain MRI - EEG within 1 week - Seizure precautions and driving advice - Outpatient neuro follow-up in 1–2 weeks
🧩 Case 2 – Challenging Case
“They said I was shaking, but I didn’t feel anything”
🔶 Doorway Information
- Age/Gender: 75-year-old female
- Chief Complaint: “My daughter told me I passed out and shook for a few seconds.”
- Vital Signs: T 36.5°C, HR 52 bpm, BP 96/58 mmHg, RR 16, SpO₂ 98% (room air)
🔶 Shoreline
The patient was brought to the clinic after a brief episode of unresponsiveness at home. According to her daughter, she suddenly slumped over, had some limb jerking, and regained consciousness within a minute.
🗂 Structured History
🔹 Opening
“I don’t remember anything. One moment I was sitting, and then I woke up on the floor.”
🔹 Onset & Course
“It happened this morning. I had just gotten up from the couch and was walking toward the kitchen.”
“My daughter said I fell, my arms and legs were jerking for a few seconds, and then I slowly woke up.”
🔹 Associated Symptoms
“No chest pain or shortness of breath. But I felt a bit lightheaded beforehand. No tongue bite, no incontinence.”
“I’ve been feeling more tired lately. Sometimes dizzy when I stand up.”
🔹 Mood / Function / Appetite / Sleep
“I’ve been sleeping okay. No major changes in appetite or mood.”
🔹 Medical History / Medication
“I have high blood pressure and take atenolol. I also had a stroke 10 years ago, no major issues since.”
🔹 Family & Social History（PAM HITS FOSS）
- Previous & Past medical history: Hypertension, old stroke
- Allergy: None
- Medication: Atenolol, amlodipine
- Hospitalization: Stroke admission 10 years ago
- Injury / Trauma / Surgery: Cataract surgery
- Family history: Father had heart disease
- OBGYN: 3 vaginal deliveries
- Sexual history: Not active
- Social history: Lives with daughter, independent at home, no alcohol or smoking
🔹 Concerns & Questions
“Am I developing epilepsy? Could this be from my heart? Should I stop my blood pressure medicine?”
🔬 Physical Examination
- General: Alert, well-appearing elderly woman
- HEENT: No trauma, pupils equal/reactive, oral mucosa intact
- Cardiopulmonary: Bradycardia (HR 52), regular rhythm, no murmurs; lungs clear
- Neuro: Alert and oriented, no focal deficits, normal gait
- Orthostatics: Drop in BP from 110/64 to 92/54 with standing, HR unchanged
🧠 Differential Diagnosis
Most likely diagnosis: Syncope (cardiogenic or orthostatic)
- Supporting: Postural context, bradycardia, prodrome, quick recovery, no postictal confusion
- Against: Brief limb movements may resemble seizure
2nd: Focal seizure with preserved awareness
- Supporting: Elderly with prior stroke; witnessed convulsion-like movement
- Against: No tongue bite, incontinence, or postictal state
3rd: Convulsive syncope
- Supporting: Common in elderly; limb jerks often occur with cerebral hypoperfusion
- Against: Must still rule out epilepsy
🧭 Clinical Reflection
Though the daughter witnessed jerking movements, the episode is more consistent with syncope than seizure. Bradycardia, orthostatic hypotension, and absence of postictal state support a cardiovascular origin. Still, further testing (e.g. ECG, Holter, EEG) is warranted given the unclear etiology.
💡 Clinical Pearls
- 🧓 Convulsive syncope often mimics seizures, especially in elderly patients.
- 📉 Bradycardia or orthostatic hypotension can be key clues—check orthostatics.
- 🩺 Always review medications like beta-blockers that may cause hypotension or bradycardia.
- 🧪 EEG may still be needed to rule out subclinical seizures after stroke.
- 🚨 Sudden LOC without prodrome + bradycardia = rule out heart block!
❓ Challenging Questions
Q: “Do I have epilepsy now?”
A: “Not necessarily. Some types of fainting can look like seizures. Your test results will help clarify whether it’s from the brain or the heart. Let’s take this one step at a time.”
Q: “Should I stop my medications?”
A: “That’s an important concern. Your blood pressure medicine might be contributing to this episode, but we shouldn’t stop it without a full assessment. We’ll review it together after we do the necessary tests.”
Q: “Could this happen again?”
A: “It’s possible, especially if related to your blood pressure or heart rhythm. But we’ll work to reduce that risk by adjusting medications if needed and possibly referring you to a cardiologist.”
📝 SOAP Note
S: 75-year-old woman brought in after brief LOC with limb jerking witnessed by daughter. Occurred while standing. No tongue bite, incontinence, or postictal confusion. Complains of recent lightheadedness. PMH of HTN and remote stroke. On beta-blocker. O: - Vitals: HR 52, BP 96/58, SpO₂ 98% - Orthostatics: ↓BP with standing, HR unchanged - Alert, no focal deficits - No trauma, tongue/mouth normal - Bradycardia on auscultation A: # Transient loss of consciousness with convulsive features # Likely syncope (bradycardia and orthostatic hypotension) # Rule out seizure vs cardiac arrhythmia ddx): Vasovagal/orthostatic syncope, seizure, cardiac arrhythmia r/o): Generalized seizure (no postictal state, no tongue bite), PNES → Bradycardia and orthostatic changes suggest syncope, but elderly patient warrants full workup. Will evaluate with ECG, labs, and consider neuro and cardio referral. P: - ECG and 24-hour Holter monitor - Labs: CBC, CMP, glucose, electrolytes - Consider EEG and brain imaging (if neuro findings emerge) - Medication review (atenolol) - Educate on fall precautions - Cardiology and neurology referral if needed
🍷 Case 3 – Interesting Case
“I had a seizure after drinking last night”
🔶 Doorway Information
- Age/Gender: 34-year-old male
- Chief Complaint: “I had a seizure this morning after a night of heavy drinking.”
- Vital Signs: T 37.1°C, HR 106 bpm, BP 134/84 mmHg, RR 18, SpO₂ 98%
🔶 Shoreline
The patient came to the clinic after experiencing a generalized seizure at home earlier this morning. He had consumed a large amount of alcohol the night before and had not eaten or slept well in the past 24 hours. No previous seizure history.
🗂 Structured History
🔹 Opening
“I woke up shaking all over this morning. My roommate said it looked like a seizure.”
🔹 Onset & Course
“I went drinking with friends last night—more than usual. I think I passed out around 2 AM. When I woke up around 7, I felt shaky, then suddenly had a blackout.”
“My roommate said I was stiff and jerking for maybe a minute or two, then confused afterward.”
🔹 Associated Symptoms
“My head hurts and I bit my tongue. I was sweating a lot. I’ve also been feeling anxious and nauseous.”
“No chest pain, shortness of breath, or fever.”
🔹 Mood / Function / Appetite / Sleep
“I haven’t been sleeping well lately, and I haven’t eaten much. Been under a lot of stress at work.”
🔹 Medical History / Medication
“I’ve never had a seizure before. No medical conditions. Not on any medications.”
🔹 Family & Social History（PAM HITS FOSS）
- Previous & Past medical history: None
- Allergy: None
- Medication: None
- Hospitalization: None
- Injury / Trauma / Surgery: None
- Family history: Father had alcohol issues
- OBGYN: N/A
- Sexual history: Active, no STIs
- Social history: Drinks alcohol 4–5x/week, binge drinking on weekends, occasional cannabis use
🔹 Concerns & Questions
“Was this a withdrawal seizure? Do I need medication? Do I have to quit drinking entirely?”
🔬 Physical Examination
- General: Slightly anxious, diaphoretic
- HEENT: Tongue bite present; no signs of trauma
- Cardiopulmonary: Tachycardic, normal rhythm, lungs clear
- Neuro: Alert and oriented, no focal signs, mild tremor of hands
- Skin: No jaundice or stigmata of chronic liver disease
🧠 Differential Diagnosis
Most likely diagnosis: Alcohol withdrawal seizure
- Supporting: Recent binge, morning onset, tremor, anxiety, tongue bite, postictal confusion
- Against: No chronic heavy use—but history suggests high risk
2nd: First-time idiopathic generalized seizure
- Supporting: Age group typical
- Against: Clear provoking factor (alcohol), no past episodes
3rd: Metabolic seizure (e.g. hyponatremia, hypoglycemia)
- Supporting: Poor nutrition, dehydration
- Against: No symptoms suggestive of major electrolyte abnormality
🧭 Clinical Reflection
This was likely an alcohol-related seizure, either due to acute withdrawal or toxicity from binge drinking. He meets criteria for alcohol use disorder and may be at risk of recurrent seizures or DTs. Early intervention and counseling are crucial.
💡 Clinical Pearls
- 🥃 Withdrawal seizures usually occur within 6–48 hours after last drink, often in chronic users.
- 🧠 A first seizure may unmask an underlying epilepsy—EEG and imaging still needed.
- 🚨 Always screen for alcohol use disorder (AUD) with tools like CAGE/CIWA.
- 💊 Benzodiazepines are first-line for withdrawal seizures—prevention is key.
- 📆 Long-term plan: CBT, support groups, or referral for rehab are often necessary.
❓ Challenging Questions
Q: “Was it because of alcohol?”
A: “It’s very likely, especially since it happened the morning after heavy drinking. Alcohol withdrawal can cause seizures, even in people who’ve never had one before. We’ll confirm with some tests to be sure.”
Q: “Will I have another seizure?”
A: “There’s a risk, especially if the drinking pattern continues. But we can reduce that risk with proper treatment and support. This is an important opportunity to take care of your health moving forward.”
Q: “Do I need to quit alcohol forever?”
A: “We’ll talk more about that together. But for now, it’s safest to avoid alcohol completely until we finish the tests and stabilize things. If alcohol is causing seizures, continuing it would be dangerous.”
📝 SOAP Note
S: 34-year-old man presents after first-time generalized seizure this morning. Occurred after heavy drinking last night. Roommate witnessed shaking and confusion. Patient reports poor sleep, stress, and binge pattern. No previous seizure history. O: - Vitals: T 37.1°C, HR 106, BP 134/84, RR 18, SpO₂ 98% - Alert but anxious; mild hand tremor - Tongue bite noted - No focal neurological signs - No jaundice or stigmata of liver disease A: # Generalized tonic-clonic seizure # Likely alcohol-related (withdrawal or toxicity) # Alcohol use disorder risk ddx): Alcohol withdrawal seizure, first-time idiopathic seizure, metabolic seizure r/o): Hypoglycemia/electrolyte imbalance (labs pending), trauma, PNES → Alcohol withdrawal seizure most likely given timing, history, and signs. Needs metabolic panel, neuroimaging, and addiction counseling. Seizure precautions advised. P: - CBC, CMP, glucose, electrolytes, LFTs - Brain MRI and EEG - CIWA-Ar scoring - Benzodiazepine PRN (e.g. lorazepam) - Brief intervention and referral to addiction services - No driving until cleared by neurology
📌 Summary
This mock script series provides realistic outpatient scenarios of seizure-related presentations, ranging from first-time generalized seizures to convulsive syncope and alcohol-related episodes. Learners are encouraged to practice clinical reasoning, differential diagnosis, and communication skills using structured frameworks like SOAP and PAM HITS FOSS.
- 🧩 Don’t jump to an epilepsy diagnosis—explore reversible and cardiac causes.
- 🛑 Always ask about red flags: tongue bite, postictal state, incontinence.
- 📋 Use systematic history tools (PAM HITS FOSS) and physical exams to guide testing.
- 💬 Practice how to respond to patient fears around epilepsy, work, and driving.
🧠 VITAMIN CDE – Broad Differential for Seizure-Like Events
- V: Vasovagal syncope, arrhythmia, stroke
- I: Infection (meningitis, encephalitis)
- T: Trauma, subdural hematoma
- A: Alcohol withdrawal, metabolic (Na, glucose, Ca)
- M: Mass lesions (tumor, AVM)
- I: Iatrogenic (drug withdrawal: BZD, AED)
- N: Neoplasm, neurodegenerative disease
- C: Congenital epilepsy syndromes
- D: Drugs/toxins (cocaine, theophylline, isoniazid)
- E: Electrolyte imbalance, epilepsy
🔗 Related Articles
- 🌀 How to Approach Syncope (English)
- 🧠 How to Approach Seizure (English)
- 🎡 Dizziness – OSCE-Ready Diagnosis Guide (English)
- 🚨 Shock – ABC & POCUS Guide (English)
- 🧠 【日本語版】けいれんの診かた – 症候別アプローチ
📚 References
- UpToDate: Approach to the first seizure in adults
- Mayo Clinic: Epilepsy Diagnosis & Management
- 日本救急医学会ガイドライン：失神の診療アルゴリズム（2022年）
- First Aid for the USMLE Step 2 CS
- ティアニー先生の診察入門
- ダ・ヴィンチのカルテ – Snap Diagnosisを鍛える99症例