First Seizure (OSCE focused)

Candidate Instructions:You are the medical student in the Emergency Department. A 25-year-old man has been brought in after collapsing at home. Take a focused history from the patient (and/or relative if you wish) about the event. Do not examine at this stage. At the end, summarise your findings and tell the examiner what investigations you would request.

Key Areas to Cover ✅

• 📅 History of the event: Before, during, after (prodrome, ictal, post-ictal).
• 👀 Witness account: Movements, duration, tongue biting, incontinence, cyanosis.
• 🧠 Risk factors: Head trauma, meningitis/encephalitis, family history of epilepsy.
• 💊 Medication & substances: Alcohol withdrawal, recreational drugs, missed medications.
• ⚠️ Red flags: Prolonged seizure, status epilepticus, focal deficit afterwards (Todd’s paresis).

Examiner Prompts 💬

• “How would you differentiate a seizure from a syncopal episode?”
• “What investigations would you arrange acutely?”

Differential Diagnoses 🔎

• Epileptic seizure (generalised tonic-clonic, focal with secondary generalisation).
• Syncope (vasovagal, arrhythmia-related).
• Non-epileptic attack disorder (psychogenic seizures).
• Metabolic: hypoglycaemia, electrolyte imbalance (Na, Ca, Mg).
• Structural brain lesion: tumour, stroke, infection.
• Alcohol/drug withdrawal or intoxication.

Mark Scheme (10 points) 📝

Investigations 🔬

• Bedside: glucose, vitals, ECG.
• Bloods: FBC, U&E, LFT, Ca, Mg, toxicology if indicated.
• Imaging: CT head acutely (exclude bleed, mass); MRI brain if safe.
• EEG (not emergency, but part of epilepsy work-up).
• Consider lumbar puncture if infection suspected (after imaging).

Management 🩺

• If actively seizing: ABC, IV access, O₂, check glucose, give IV lorazepam.
• Post-ictal but stable: supportive care, safety (side positioning, airway protection).
• Do not start long-term antiepileptics after a single seizure without neurology review (unless high risk).
• Advise driving restrictions (UK: no driving for 6 months after first unprovoked seizure).
• They must refer themselves to the DVLA for a forma assessment
• Arrange urgent neurology referral for outpatient follow-up.

Teaching Commentary 📚

This is a high-yield OSCE: examiners want to see if you can structure a history around an unwitnessed collapse. Always anchor your approach in the “3 phases” (before, during, after). Remember red flags (status, focal neurology, head trauma, infection). For management, your priority is stabilisation and exclusion of reversible causes. The DVLA driving restriction is a classic exam point 🚗❌.

🧑‍⚕️ Case Examples - First Seizure

• Case 1 (Generalised Tonic-Clonic Seizure): ⚡ A 22-year-old man collapses at a party with sudden stiffening and generalised jerking movements lasting 90 seconds. He bites his lateral tongue and is confused for 30 minutes afterwards. Blood glucose is normal; CT head clear. Diagnosis: First generalised tonic-clonic seizure. Teaching point: Classic features include tonic–clonic movements, tongue biting, and post-ictal confusion; workup requires EEG and neuroimaging.
• Case 2 (Focal Aware Seizure): 🧠 A 30-year-old woman reports recurrent episodes of seeing flashing lights in her right visual field lasting 30 seconds, without loss of awareness. MRI shows an occipital cortical lesion. Diagnosis: First focal aware (simple partial) seizure. Teaching point: Symptoms reflect the cortical origin - visual aura suggests occipital lobe involvement.
• Case 3 (Focal Impaired Awareness Seizure with Secondary Generalisation): 🔄 A 35-year-old man experiences a rising epigastric sensation followed by blank staring and lip smacking. Witnesses describe progression into tonic-clonic movements. MRI shows left temporal gliosis. Diagnosis: Focal seizure with impaired awareness, secondarily generalised. Teaching point: Aura + automatisms point to temporal lobe epilepsy; always look for underlying structural pathology.
• Case 4 (Provoked Seizure - Alcohol Withdrawal): 🍺 A 45-year-old man with alcohol dependence develops a generalised tonic-clonic seizure 24 hours after stopping drinking. Bloods show hypomagnesaemia. Diagnosis: Alcohol withdrawal seizure. Teaching point: Provoked seizures require treating the underlying cause; benzodiazepines are first-line for withdrawal.
• Case 5 (Seizure Mimic - Syncope): ❤️ A 60-year-old man faints while queueing, with brief limb jerks observed. Recovery is rapid, with no post-ictal confusion. ECG reveals complete heart block. Diagnosis: Syncope due to cardiac arrhythmia. Teaching point: Not all "fits" are epileptic; always consider cardiac causes, especially in older adults.