Station 34
Michelle Williams
Age: 23 years old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the seizure episode in detail, including whether there was any witness to the event.
- Ask about the type of seizure, presence of aura, loss of consciousness and post ictal symptoms (Post ictal sleep, incontinence, amnesia and confusion).
- Ask about any potential triggers, such as; sleep deprivation, infection (e.g. flu-like symptoms, UTI), emotional stress, light sensitivity, alcohol use etc.
- Ask screening questions to rule out red flags suggestive of: Brain tumour (e.g. persistent headache, visual changes, focal weakness), Intracranial infection (e.g. fever, neck stiffness, photophobia, feeling generally unwell)
- Ask about social history, including smoking, alcohol intake, illicit drug use, and occupation (especially if the patient works in a high-risk environment such as operating machinery, driving, or working at heights).
- Ask if the patient is sexually active, as Tegretol (carbamazepine) has implications for contraception, which is important if she is being considered for restarting the medication.
- Ask whether the patient drives, as this has medicolegal and safety implications.
- Explore the reason for stopping her medication and missing neurology follow-up.
- Provide a working diagnosis of uncontrolled epilepsy as the likely cause of her recent seizure.
Example of explanation to patient
Michelle, based on the symptoms you’ve described—such as waking up with a bitten tongue and having wet yourself, it does sound like you may have had a seizure episode during your sleep. Seizures can be triggered by a number of things including stress, lack of sleep, infections, alcohol, or even certain medications. Sometimes, there’s no clear trigger at all.
I’d like to arrange a face-to-face review so I can examine you properly and organise some blood tests to rule out any underlying medical causes. Would that be okay?
It’s also really important that we talk about your medication. Stopping your anti-epileptic treatment suddenly, even if you’ve been doing well, can increase your risk of having another seizure. I understand why you stopped it, but in the future, it’s safest to speak to your GP or specialist before making that decision.
I’ll restart you on your previous dose of Tegretol (carbamazepine), and I’ll also send an urgent referral to the neurology team and the epilepsy clinic so they can review you again as soon as possible.
You mentioned that you drive. Unfortunately, once you’ve had a seizure, even if it happened during sleep, you must stop driving and inform the DVLA. I know this may be difficult, but it’s about keeping both you and others safe on the road. The DVLA will guide you on when you’re able to drive again depending on how things progress.
Before restarting your medication, we also need to talk about contraception. Tegretol can make some contraceptives less effective, and if you were to become pregnant, there’s a small increased risk of birth defects with this medication. To keep things safe, I’d advise using condoms for now, and we can book another appointment to discuss longer-term contraception options that are more reliable. I’ll send you some information leaflets and helpful links so you can read more about this in your own time.
Because you live alone, you might want to consider an epilepsy alarm. These devices detect unusual movements during a seizure and can alert a family member, neighbour, or emergency contact, so they know how best to help you if needed.
Until we’ve got this under control, it’s best to avoid:
- Working with heavy machinery
- Swimming alone or use of baths (opt for showers instead)
- Climbing or working at heights
Lastly, try to avoid known triggers like sleep deprivation, alcohol, flashing lights, or high stress levels, as they can make seizures more likely.
If you do experience any more seizures, or new symptoms like headaches, blurry vision, or weakness, please don’t hesitate to get in touch right away.
How does that all sound to you? Do you have any questions or worries you’d like to go over together?
Management
- Restart antiepileptic medication at the previous effective dose (Tegretol 400 mg BD), as the patient has had a breakthrough seizure likely due to self-discontinuation.
- Refer urgently to the Neurology team for further assessment and specialist follow-up.
- Offer a face-to-face appointment for neurological examination, blood pressure and temperature check, and arrange blood tests including electrolytes, FBC, CRP, LFTs, and TFTs.
- Educate the patient on medication adherence, emphasising that she should not stop antiepileptic medication without medical advice, as sudden withdrawal increases the risk of seizure recurrence and complications.
- Advise immediate cessation of driving and the need to inform the DVLA, as legally required following any seizure, including nocturnal ones. Explain safety concerns and legal obligations.
- Arrange a follow-up appointment to discuss contraceptive options in detail, given that carbamazepine can reduce the effectiveness of some contraception (COCP for example) and carries a small risk of congenital abnormalities if pregnancy occurs. In the interim, advise the use of condoms for protection.
- Recommend wearing a medical alert bracelet to ensure that, in the event of a seizure in public, bystanders or emergency responders are aware of her diagnosis and can offer appropriate help.
- If the patient lives alone, suggest investing in an epilepsy seizure alarm—devices that detect unusual movement during sleep or while awake and can alert designated contacts. These are commercially available.
- Encourage the patient to inform close contacts (e.g. partner, friends, colleagues) about her epilepsy so they know how to assist during a seizure—such as placing her in the recovery position and administering rescue medication (e.g. buccal midazolam or rectal diazepam) if prescribed by specialist.
- Provide safety netting advice: if she experiences any further seizures, blurry vision, headache, focal weakness, or any other concerning symptoms, she should seek urgent medical advise
Learning point from this station:
If seizures recur during or after the discontinuation of an antiepileptic drug, the last dose should be restarted and urgent guidance sought from an epilepsy specialist. This case highlights the serious risks associated with non-adherence to epilepsy medication, including Sudden Unexpected Death in Epilepsy (SUDEP).
SUDEP is defined as the sudden, unexpected, non-traumatic, and non-drowning death of a person with epilepsy, with or without a witnessed seizure, and in whom no structural or toxicological cause is found post-mortem, excluding status epilepticus. It is thought to result from severe, centrally mediated respiratory and cardiac suppression following a generalised tonic-clonic seizure, particularly during the postictal phase. Approximately 60% of cases occur during sleep. Having seizures during sleep increase the risk of Sudden Unexpected Death in Epilepsy (SUDEP)
SUDEP is the leading cause of epilepsy-related death in young adults with uncontrolled epilepsy, and the risk can be significantly reduced through effective seizure control and medication adherence. This underlines the importance of close follow-up, patient education, and specialist involvement in the care of patients with epilepsy.