first seizure
Doctor Information
Bobby Carter, age 21
PMH
Fracture distal radius and ulna 2009
Asthma (resolved 2007)
No regular medications or known drug allergies
PMH
Fracture distal radius and ulna 2009
Asthma (resolved 2007)
No regular medications or known drug allergies
Patient Information
Bobby Carter, age 21
History: You have come about an indecent that happened at the gym earlier this week. You were on the cross trainer and you felt a bit weird. Next thing you know you are in the back of an ambulance being driven to A+E - other people at the gym said you just went a bit funny, then collapsed and started shaking. You also wet yourself which you are mortified about as there are loads of really attractive young fillies at gym. You weren't in A+E very long - they did some blood tests which were ok and a trace of your heart which again was ok. They said you might have had a fit, and that I should come to see you today
If asked only: This is the first incident like this. You were feeling fine that morning, and you do a lot of gym, at least three times a week with no problems. You definitely blacked out, as you have no memory of that period after you collapsed. You think, from what people said, that your arms and legs were all shaking. You did not bite your tongue. You felt a bit out of it afterwards, sort of like groggy as though you were hungover. You feel fine now, and nothing has happened since.
You work as an apprentice for a plumbing company, hoping to get a contract with them at the end of the year. Your job involves sorting through the calls, going to make assessments at client’s houses, and then carrying out the work. You are doing pretty well with it- your boss Eddie lets you do most things on your own as you have been training for 2 years now. You are looking forward to being a proper contract plumber. You obviously do have to drive, to get to people’s houses - you currently use one of the company vans. You live with your girlfriend Marley and your 2 year old daughter Stacey. You are the only earner.
You are usually pretty healthy - there was a skiing accident a few years ago where you broke your arm, and you had asthma as a kid, but no issues now. No medication or allergies. You do not smoke or drink alcohol - you just wouldn't manage the early starts if you did. No family history of epilepsy.
Ideas: that this was just a faint. No big deal, you feel fine.
Concerns: You have read that a fit can cause people their license, and you can not afford to be without yours.
Expectations: that the GP will disagree with A+E, and let you go home and carry on as usual.
If/When the issue of managing a first seizure is discussed with you, you panic. You are fine to go and see a consultant and have a brain scan (EEG) but you cannot give up driving for any length of time. You are so close to finishing your training and you have worked really hard for 2 years now. Besides what about money - you are the only one bringing money in. You will calm down if the doctor is understanding and discussed things with you - when you think about it there may be an opportunity at work to switch to a new site where you could get the public transport there and back, and if the doctor is willing to write a fit note to that effect you fwill feel happier. You are not happy about it but will eventually agree to tell the DVLA. Regarding the seizure, you hadn't even thought about the possibility of having another one. You are keen to listen to the first aid rules if it happens again so you can tell Marley and your colleagues, and this perhaps makes you understand more how important it is to get a specialist involved and do this by the book.
History: You have come about an indecent that happened at the gym earlier this week. You were on the cross trainer and you felt a bit weird. Next thing you know you are in the back of an ambulance being driven to A+E - other people at the gym said you just went a bit funny, then collapsed and started shaking. You also wet yourself which you are mortified about as there are loads of really attractive young fillies at gym. You weren't in A+E very long - they did some blood tests which were ok and a trace of your heart which again was ok. They said you might have had a fit, and that I should come to see you today
If asked only: This is the first incident like this. You were feeling fine that morning, and you do a lot of gym, at least three times a week with no problems. You definitely blacked out, as you have no memory of that period after you collapsed. You think, from what people said, that your arms and legs were all shaking. You did not bite your tongue. You felt a bit out of it afterwards, sort of like groggy as though you were hungover. You feel fine now, and nothing has happened since.
You work as an apprentice for a plumbing company, hoping to get a contract with them at the end of the year. Your job involves sorting through the calls, going to make assessments at client’s houses, and then carrying out the work. You are doing pretty well with it- your boss Eddie lets you do most things on your own as you have been training for 2 years now. You are looking forward to being a proper contract plumber. You obviously do have to drive, to get to people’s houses - you currently use one of the company vans. You live with your girlfriend Marley and your 2 year old daughter Stacey. You are the only earner.
You are usually pretty healthy - there was a skiing accident a few years ago where you broke your arm, and you had asthma as a kid, but no issues now. No medication or allergies. You do not smoke or drink alcohol - you just wouldn't manage the early starts if you did. No family history of epilepsy.
Ideas: that this was just a faint. No big deal, you feel fine.
Concerns: You have read that a fit can cause people their license, and you can not afford to be without yours.
Expectations: that the GP will disagree with A+E, and let you go home and carry on as usual.
If/When the issue of managing a first seizure is discussed with you, you panic. You are fine to go and see a consultant and have a brain scan (EEG) but you cannot give up driving for any length of time. You are so close to finishing your training and you have worked really hard for 2 years now. Besides what about money - you are the only one bringing money in. You will calm down if the doctor is understanding and discussed things with you - when you think about it there may be an opportunity at work to switch to a new site where you could get the public transport there and back, and if the doctor is willing to write a fit note to that effect you fwill feel happier. You are not happy about it but will eventually agree to tell the DVLA. Regarding the seizure, you hadn't even thought about the possibility of having another one. You are keen to listen to the first aid rules if it happens again so you can tell Marley and your colleagues, and this perhaps makes you understand more how important it is to get a specialist involved and do this by the book.
Examination Findings
PERLA
Normal fundi
Cranial nerves 2-12 NAD
Perhipheral nerves - equal tone, power, reflexes and sensation
Pulse 86
Normal fundi
Cranial nerves 2-12 NAD
Perhipheral nerves - equal tone, power, reflexes and sensation
Pulse 86
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation - enquires about social history / work / driving / hobbies Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise Fails to mention driving rules. Fails to offer support with work if asked for. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient to contact DVLA himself Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation: A seizure, or fit happens when there is a surge in electrical activity inside the brain. One seizure can happen for any number of reasons, and needs investigating to find the cause. This is done by a specialist. Treatment is not necessarily required.
In this scenario, the seizure history is quite an obvious one, but that isn't the only aspect to this case. Regarding the seizure, establish the history and any background, previous seizures or family history of epilepsy. Referral depends on your local services - sometimes you are required to organise bloods (mainly for electrolyte imbalance) and an ECG. There should either be a first fit clinic that you can refer directly to, or an acute neurology clinic. The patient should ideally be seen within 2 weeks, and in the meantime given advice on first aid to teach their friends and family, should another fit occur.
Another thing to mention is that it's always important to ask about the patient's hobbies, as he may like to cycle on the road, or swim in lakes, or go rock climbing etc.. You need to establish what he does that is or is not safe given that he may have had a seizure and may have another one without warning. It's always important to advised not to swim, unless with someone, or not to go cycling on a main road etc..
The other issue is driving. Even with a single seizure, the patient cannot drive until they have been assessed by a specialist. This is often a contentious issue for patient, because there is a great deal of uncertainty about how long it may be for etc, and people may depend on their vehicle for work. A first seizure earns you 6 months without a drivers licence for group 1 licence holders, and 5 years for group 2 holders. Regaining your licence depends on the neurology assessment and risk of further seizures. If you find that your patient is reluctant or even unwilling to revoke their licence while undergoing investigation, you must be honest with them - if they do not inform the DVLA and stop driving, it is your duty to inform the DVLA yourself. Also their vehicle insurance is invalid if they have been advised not to drive.
As for a fit note, it would not be unreasonable to help support him with his employment by writing a fit note stating that he can not drive. This is not always required however, as his employer may be able to arrange something without a sick note.
In this scenario, the seizure history is quite an obvious one, but that isn't the only aspect to this case. Regarding the seizure, establish the history and any background, previous seizures or family history of epilepsy. Referral depends on your local services - sometimes you are required to organise bloods (mainly for electrolyte imbalance) and an ECG. There should either be a first fit clinic that you can refer directly to, or an acute neurology clinic. The patient should ideally be seen within 2 weeks, and in the meantime given advice on first aid to teach their friends and family, should another fit occur.
Another thing to mention is that it's always important to ask about the patient's hobbies, as he may like to cycle on the road, or swim in lakes, or go rock climbing etc.. You need to establish what he does that is or is not safe given that he may have had a seizure and may have another one without warning. It's always important to advised not to swim, unless with someone, or not to go cycling on a main road etc..
The other issue is driving. Even with a single seizure, the patient cannot drive until they have been assessed by a specialist. This is often a contentious issue for patient, because there is a great deal of uncertainty about how long it may be for etc, and people may depend on their vehicle for work. A first seizure earns you 6 months without a drivers licence for group 1 licence holders, and 5 years for group 2 holders. Regaining your licence depends on the neurology assessment and risk of further seizures. If you find that your patient is reluctant or even unwilling to revoke their licence while undergoing investigation, you must be honest with them - if they do not inform the DVLA and stop driving, it is your duty to inform the DVLA yourself. Also their vehicle insurance is invalid if they have been advised not to drive.
As for a fit note, it would not be unreasonable to help support him with his employment by writing a fit note stating that he can not drive. This is not always required however, as his employer may be able to arrange something without a sick note.