HISTORY A twenty year old college football player collapsed unprovoked on the field on a hot summer day during the first game of the season. There was no witnessed head trauma or other significant injury. He exhibited altered consciousness with shaking for approximately four minutes. With C-spine precautions, EMS transported the athlete to the nearest ER. Later history revealed the athlete had had little sleep or oral intake prior to the game. His past history included one questionable seizure episode two years prior. Workup at that time failed to find a seizure etiology. The athlete, otherwise healthy, denied taking any medicines, supplements, or drugs. There was no family history of seizures. PHYSICAL EXAMINATION Examination on the field revealed a young man exhibiting jerking movements of all extremities. He was audibly breathing through clenched teeth, and foaming at the mouth. He was hypertensive to 170/40, and tachycardic to 140bpm. There were no obvious signs of head or neck trauma. In the ER, vitals were within normal limits, as were the cardiac, lung and abdominal exams. Neurological exam revealed a groggy, somewhat disoriented young man with cognitive slowing. DIFFERENTIAL DIAGNOSIS Heat Exhaustion/Dehydration Seizure: Epileptic vs. Concussive Concussion Hypoglycemia Tachy/Bradyarrythmia Cervical Spine Injury Stroke TESTS AND RESULTS Electrolytes: normal, except for glucose, 64 Head CT: normal Neuropsychological testing: transient cognitive deficits Sleep deprived EEG: possible focus of increased activity FINAL/WORKING DIAGNOSIS Epileptic seizure with multiple contributing factors. TREATMENT AND OUTCOMES Airway protection, C-spine precautions, EMS transport. Load with IV phenytoin and continue oral phenytoin. Remove from all athletic activity until stable on medicines, workup complete and cognitive function normalized. Counsel regarding: seizure risk reduction, academic support and driving restrictions. Extensive discussions with the athlete and his family about return to play issues. Return to sport 8 weeks post seizure, stable on phenytoin, with particular attention to nutrition, hydration and rest.