Makindo Medical Notes

⚡ OSCE – First Seizure

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 🚗❌.